Fwd: A Black Hole of Patient Safety

Mark Gusack gusackm at COMCAST.NET
Thu Sep 15 01:34:40 UTC 2016


Good Evening Everyone:

 

I appreciate Dr. Kanter’s reply.  And I just finished looking at the eAutopsy articles!  Interesting.

 

One of the issues these articles bring to the forefront is the problem we have with retrospection.  Shouldn’t we have systems in place to catch this before the eAutopsy has to be carried out?  In my opinion there are three ways to deal with error:

 

Retrospective:              Bad.                       It’s too late.  The damage is done.

Concurrent:                  Better.                  Perhaps we can prevent or mitigate some of the damage done.

Prospective:                   Best.                      We can avoid situations that cause error or prevent error when they arise eliminating most if not all the damage.

 

What would be ideal is a near real time eAutopsy that would head off the unnecessary death!  And then, if a death occurred a confirmatory rAutopsy [Real Autopsy].

 

Mark Gusack, M.D.

Staff Pathologist

Huntington VAMC

 

From: Michael.H.Kanter at kp.org [mailto:Michael.H.Kanter at kp.org] 
Sent: Wednesday, September 14, 2016 10:05 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG; gusackm at COMCAST.NET
Subject: Re: [IMPROVEDX] Fwd: A Black Hole of Patient Safety

 

As a pathologist, I have also seen the autopsy really become done less frequently over the years. It can be a valuable source of finding errors (not just diagnostic) but has some limitations that include high cost and time involved, potentially biased sample of cases in that consent is required and often not obtain, and lack of reimbursement for the pathologist.   Most importantly, the autopsy is really designed to only detect errors that are discovered when there is a discrepancy between the findings at autopsy and the premortem diagnosis and is not really designed to see patterns of errors unless one has a good system to collate the results of autopsies done over time. .   
         There is a method to still study deaths that we have published that we call the e-autopsy that offers some advantages.  One can review a much larger sample of deaths,trend results over time, and see patterns in care that are less obvious than when reviewing single autopsies.  In many cases, if one looks carefully,  the diganostic error is discoverable prior to death.   As an example, this method allowed us to realize that we had an issue with failure to diagnose and then follow up on aortic aneurysms (some AAA were seen by the radiologists but not noticed by the physicians taking care of the patient) and so we set up a system to do mitigate this.  The e autopsy is limited in that it will not identify diagnostic errors that were never discovered prior to death though.  Thus, I believe that the regular and e autopsy are complimentary.  Attached is an article on the e autopsy process as well as a more recent one focused on deaths from colon cancer.   






Michael Kanter, M.D., CPPS
Regional Medical Director of Quality & Clinical Analysis 
Southern California Permanente Medical Group
(626) 405-5722 (tie line 8+335) 

Executive Vice President, 
Chief Quality Officer, 
The Permanente Federation 

THRIVE By Getting Regular Exercise

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From:        Mark Gusack <gusackm at COMCAST.NET <mailto:gusackm at COMCAST.NET> > 
To:        IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>  
Date:        09/13/2016 06:43 PM 
Subject:        Re: [IMPROVEDX] Fwd: A Black Hole of Patient Safety 

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Caution: This email came from outside Kaiser Permanente. Do not open attachments or click on links if you do not recognize the sender. 

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Good Evening Everyone: 
  
I am a pathologist and I can tell you that, because of the way autopsies were supported in hospitals in the past and because of fear of litigation, autopsies are few and far in between.  If we are to restart the use of autopsies as a means of: 
  
Æ  Confirming our diagnoses 
Æ  Validating our therapies 
Æ  Teaching our students and residents 
  
Then we will need to find: 
  
Æ  The funding – autopsies are very expensive and labor intensive 
Æ  The pathologists willing to do them – they’re messy and did I mention labor intensive 
Æ  The means of reducing the threat of litigation 
  
If we do this, then I can tell you from experience that the results will be eye opening.  For example, in most of my autopsies where there has been a prior coronary artery bypass graft or two, most are not functional due to organized clots and secondary fibrosis of the pericardium that obstructs flow.  So that raises the question of what is going on with this operation. 
  
Everyone have a good rest of the week. 
  
Mark Gusack 
Staff Pathologist 
Huntington VAMC 
  
From: Mark Graber [ <mailto:mark.graber at IMPROVEDIAGNOSIS.ORG> mailto:mark.graber at IMPROVEDIAGNOSIS.ORG] 
Sent: Tuesday, September 13, 2016 10:46 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG> 
Subject: [IMPROVEDX] Fwd: A Black Hole of Patient Safety 
  
George, I’ve taken the liberty of sharing your email and the link to the article with the SIDM listserv audience.  You’ve raised an extremely important point, that without autopsies we’ll never know if a cancer death was the result of the malignancy or its treatment.  The IOM report “Improving Diagnosis in Health Care” called for more autopsies in the US.  The example you cite is another argument in favor of this recommendation. 
  
Thanks for calling this to attention, 
  
Mark 
  
Mark L Graber MD FACP 
Senior Fellow, RTI International 
Professor Emeritus, SUNY Stony Brook 
President, Society to Improve Diagnosis in Medicine 
  
  
  
  
Begin forwarded message: 
  
From: George < <mailto:gdlundberg at gmail.com> gdlundberg at gmail.com> 
Subject: A Black Hole of Patient Safety 
Date: September 13, 2016 at 10:13:37 AM EDT 
To: Elizabeth Burton < <mailto:ecburtonmd at gmail.com> ecburtonmd at gmail.com>, "Dr. Kaveh Shojania" < <mailto:kaveh.shojania at sunnybrook.ca> kaveh.shojania at sunnybrook.ca>, "R.E.Horowitz" < <mailto:r.e.horowitz at ucla.edu> r.e.horowitz at ucla.edu>,  <mailto:robert.wachter at ucsf.edu> robert.wachter at ucsf.edu 
Cc: Mark Graber < <mailto:mark.graber at improvediagnosis.org> mark.graber at improvediagnosis.org>, Paul Epner < <mailto:paul.epner at improvediagnosis.org> paul.epner at improvediagnosis.org> 
Resent-From: < <mailto:Mark.Graber at improvediagnosis.org> Mark.Graber at Improvediagnosis.org> 
  
Good morning, 
Please open this 2012 article. I believe that it is open access, full text. 
http://www.nature.com/bjc/journal/v107/n1/full/bjc2012252a.html 
  
In my CollabRx role, I attended an all day program on Targeted Therapy vs Immunotherapy in advanced cancer.....all types, last Saturday; many academic hotshots. Large numbers of expensive clinical trials inform the field. Progression free survival PFS and overall survival OS are the holy grail of data. And, in fairness, some PPs did address adverse effects. 
Next week I will be publishing a blog at Curious Dr. George by Professor Michael Baum of University College London. He argues eloquently that Quality of Life is co-equal to Length of Life in those  cancer patients who progress beyond curative standard of care (700 000 Americans annually). 
One speaker lamented the difficulty of academically studying frequency/severity of adverse effects in reports of clinical trials. 
Why did autopsies in clinical trials fall off the cliff? How can the investigators draw meaningful conclusions about beneficial vs harmful effects of these very powerful new agents without autopsies? Was it the cancer or the treatment that killed the patient? 
Considering the cost of current cancer therapeutics, routine autopsy costs would be trivial. 
Reactions??? 
Best, 
george 
  
  
George D Lundberg, MD 
Chief Medical Officer and Editor in Chief, CollabRx, a Rennova Health Company 
Editor at Large, Medscape 
Consulting Professor of Pathology and Health Research and Policy, Stanford 
Executive Adviser, Cureus 
President and Board Chair, The Lundberg Institute 
312 560 0290 cell 
@glundberg 
gdlundberg at gmail.com <mailto:gdlundberg at gmail.com>  
  
Sent from my iPad mini 
  
  

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