Beyond biases?

Bob Latino blatino at RELIABILITY.COM
Thu Feb 9 17:14:03 UTC 2017


Thank you for the clarification Dr. Mittal.

For full disclosure purposes of my own, while I appreciate being addressed as 'Dr. Latino', I have not earned the distinction.  I want to avoid a 'stolen valor' type of situation:-)

I am glad to hear the case I posted at least highlighted the possibility of an anaphylactoid reaction, and created awareness.  I know in my travels, mostly acute care hospitals, many (actually most) were not aware of such a reaction.

Thanks
Bob Latino

Robert J. Latino, CEO
Reliability Center, Inc.
1.800.457.0645
blatino at reliability.com
www.reliability.com
[linkedin logo signature file]<https://www.linkedin.com/company/958495?trk=tyah&trkInfo=clickedVertical%3Acompany%2CclickedEntityId%3A958495%2Cidx%3A1-1-1%2CtarId%3A1464096807851%2Ctas%3Areliability%20center%2C%20inc.>

From: Mittal, Manoj K [mailto:MITTAL at email.chop.edu]
Sent: Thursday, February 09, 2017 11:57 AM
To: Bob Latino <blatino at reliability.com>; IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] Beyond biases?


Hi Dr Latino,

Your post was great, and much appreciated. It made me wonder (and Google it) about the difference between anaphylactic and anaphylactoid reactions, as somehow in pediatrics we don't make the latter diagnosis much - not sure if it is due to our ignorance or is the phenomenon less common in children because of host factors/agent-the medicines causing it are used rarely in children!

It was some of the earlier comments, tending to cast aspersions on the involved physicians.



Thanks,

Manoj



________________________________
From: Bob Latino <blatino at reliability.com<mailto:blatino at reliability.com>>
Sent: Thursday, February 9, 2017 9:24 AM
To: Mittal, Manoj K; IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Cc: Bob Latino
Subject: RE: [IMPROVEDX] Beyond biases?

Dr. Mittal

I'm not sure if your comment at my post or not, but certainly my point was not to disparage anyone (or seek such).

Earlier, we were discussing rare conditions that may be overlooked (not diagnosed properly) if the symptoms presented were similar to more common, often seen conditions.

In the case of an anaphylactoid reaction, which I understand to be rare, I was interested to see if others may not have considered it a possibility, given the symptoms were similar to an anaphylactic condition.

If this was in poor taste, I apologize as that was not the intent.

Regards
Bob Latino

Robert J. Latino, CEO
Reliability Center, Inc.
1.800.457.0645
blatino at reliability.com<mailto:blatino at reliability.com>
www.reliability.com<http://www.reliability.com>
[linkedin logo signature file]<https://www.linkedin.com/company/958495?trk=tyah&trkInfo=clickedVertical%3Acompany%2CclickedEntityId%3A958495%2Cidx%3A1-1-1%2CtarId%3A1464096807851%2Ctas%3Areliability%20center%2C%20inc.>

From: Mittal, Manoj K [mailto:MITTAL at email.chop.edu]
Sent: Thursday, February 09, 2017 8:46 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>; Bob Latino <blatino at reliability.com<mailto:blatino at reliability.com>>
Subject: Re: [IMPROVEDX] Beyond biases?


We need to be careful about casting aspersions on our colleagues without full information.

Let us also keep the discussion professional and avoid using expressions in poor taste!

Thanks,

Manoj



Manoj Mittal, MD

Pediatric Emergency Medicine,

CHOP



________________________________
From: Bob Latino <blatino at RELIABILITY.COM<mailto:blatino at RELIABILITY.COM>>
Sent: Thursday, February 9, 2017 7:06 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] Beyond biases?

Excellent post Dr. Regan!

As a patient, I appreciate your candor and tact.

I am not a clinician but work with many clinicians in my work of investigating medical error.  I essentially am a professional questioner:-)

I am curious to see if you think most residents would identify the Anaphylactoid Reaction in this case, or if you think most would misdiagnosis it based on your comments below (related to familiarity with the norms).

Here is the case background:

A 63-year-old male had been on enalapril for one year for treatment of hypertension. He experienced some difficulty swallowing and discomfort in the back of his throat. He was instructed by his doctor to go to the emergency room of a local hospital.  Upon arrival in the ED, he was noted to be experiencing mild difficulty breathing and treated with intramuscular diphenhydramine and oxygen by mask. Within 30 minutes, he was breathing more comfortably and subsequently admitted to a general medical floor for overnight observation.  The next morning, the patient's wife arrived with a bag of her husband's "other medications," which she said she administered to her husband every day. The nurse called the admitting physician and received permission to administer these medications, including another dose of enalapril. The patient was discharged later that day.  The day after discharge, the patient suffered an episode of acute angioneurotic edema with dysphagia, lip swelling ,and airway obstruction. He expired before paramedics could respond.

Patient Death Due to Medication Error and Missed Diagnosis of Anaphylactoid Reaction
https://www.youtube.com/watch?v=3XkQAsXWAmM<https://www.youtube.com/watch?v=3XkQAsXWAmM%20> (15 minute YouTube video)

Understanding what goes through the mind of any decision-maker, seeking the reasoning for the decision, is where the gold is.  The key to an effective safety investigation is understanding why well-intentioned people felt the decision they made at the time, was the correct one.

We tend to focus only on the bad outcome and disciplining the decision-maker, but we don't strive hard enough to learn why the decision-maker thought it was the appropriate decision.  This will lead us into understanding latency, or deficiencies in our management systems.


Robert J. Latino, CEO
Reliability Center, Inc.
1.800.457.0645
blatino at reliability.com<mailto:blatino at reliability.com>
www.reliability.com<http://www.reliability.com>
[linkedin logo signature file]<https://www.linkedin.com/company/958495?trk=tyah&trkInfo=clickedVertical%3Acompany%2CclickedEntityId%3A958495%2Cidx%3A1-1-1%2CtarId%3A1464096807851%2Ctas%3Areliability%20center%2C%20inc.>

From: Regan, Elizabeth [mailto:ReganE at NJHEALTH.ORG]
Sent: Wednesday, February 08, 2017 8:51 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] Beyond biases?

I think that it is important to recognize that there is a lot of "pig-headedness" in diagnostic error.  We (as a group) spend a lot of time thinking from the point of view of academic physicians who are strongly invested in diagnostic excellence.  Unfortunately, the real world is very different.
The really awful diagnostic errors like those that Jason points out are compounded and may be more common in closed systems that have a culture that resists the concept that rare diseases actually happen.  For me, the exciting and engaging aspect of medicine is the concept that any patient who walks/rolls into my exam room may have something different, unusual, interesting - and it is my job to sniff it out.  I need to use all of my experience, skills and knowledge to do that.  This excitement and engagement does not mean that I waste time, money, energy on useless directions - it means that I think about the problem and try to plot a strategy.  And I talk with the patient about what I am considering, why I would defer certain tests now and why I want them to return and report how they are doing.

If you are convinced that your patients are boring and have the same old URI, diabetes checkup, back pain .... Whatever.  Then you are not looking or thinking about the "possibles" and are extremely unlikely to find them.
I suspect that the 5 yo with juvenile arthritis was ignored repeatedly because no one imagined the possibility.

20 visits is unconscionable.  Absolutely, a flag to identify patients like that would be a really good way for a health care system to make sure that bad things aren't missed.
But why isn't that already part of the system?

I think that we have abandoned the clinical conferences and interactions that used to be part of medicine.  They were lost to a desire to have "lifestyle" and the oft repeated "I don't want to stay later in the day so I can attend a noon conference".  And with the horribly inefficient administrative processes - there really is less time.

Then there are concerns about are we training physicians properly - or just asking them to do computer data entry and refer patients for screening tests.  I find that I can't get primary care physicians to leave their screening agenda (that they may get a monetary bonus for completing) and deal with my real needs (the stuff on my problem list) and think about me as an individual.  This is the idea behind personalized medicine - "me and my genome and how I am manifesting disease now that I am 63".  I fear that young physicians in training are not having enough exposure to differential diagnosis and too much exposure to how to code diagnoses and the mechanics of a visit.  I am also concerned that we have produced so much literature/conversation about un-necessary testing that they are afraid to consider a less common diagnosis for fear that they might order a test that is negative.  I lump this into a term "dumbing down" the diagnostic problem where only the common causes are considered.

The number of times I have encountered physicians who are just plain wrong in the way that they interpret a test result or perform a diagnostic physical exam is shocking.

When I had an episode of motor loss due to an autoimmune problem  - 4 out 7 examiners failed to identify the motor deficit and didn't know how to properly do an exam to evaluate the problem.
I was shocked.
One of them was a resident - so I offered to show him how to do the exam properly.  He wasn't interested.

I have had a number of physicians mis-interpret the results of diagnostic testing for family members, children, and myself.  For example: a test that is positive in 60% of patients with a known disease - you cannot say that a negative test means that the patient does not have a condition.
A rapid strept test that is negative - does not mean that one has excluded the diagnosis of a strept infection.
Resistance to testing symptomatic patients for a disease - and not understanding that the metrics for predictive values are totally different from what is published about screening healthy asymptomatic people.
The list goes on endlessly

I know so many good and careful physicians  - and even when they try their best - they can't always be perfect.  However, as a profession we have a bigger problem and that includes: systems that do not support diagnostic accuracy, staff that do not facilitate communications, physicians who are lazy, poorly trained and disinterested - and with time/thought we could generate a bigger list.

For each of these categories there needs to be a set of diagnostic exercises (for the problem), a plan to improve and a monitoring method to assess the improvement.

Sorry for the Rant.

The conversation has been stimulating.

Liz

Elizabeth A. Regan MD, PhD
Associate Professor of Medicine
National Jewish Health
1400 Jackson St, K706
Denver, CO 80206


From: Jason Maude <jason.maude at ISABELHEALTHCARE.COM<mailto:jason.maude at ISABELHEALTHCARE.COM>>
Reply-To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>" <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>, Jason Maude <jason.maude at ISABELHEALTHCARE.COM<mailto:jason.maude at ISABELHEALTHCARE.COM>>
Date: Tuesday, February 7, 2017 at 12:22 PM
To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>" <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>
Subject: [IMPROVEDX] Beyond biases?

These 2 tragic cases of misdiagnosis have been reported recently by the Daily Mail:


1.      The first is a 5 year old boy with a missed diagnosis of juvenile arthritis  http://www.dailymail.co.uk/news/article-4198822/Boy-died-arthritis-two-years-misdiagnosis.html

2.      The second covers a 24 year women with a missed diagnosis of brain tumor http://www.dailymail.co.uk/health/article-4172188/Fit-intelligent-woman-24-dies-brain-tumour.html

The most significant aspect of both these cases is that in the first the patient was seen 20x over 2 years by clinicians and in the second 14x over 9 months!

With this number of visits we must have gone beyond 'biases' to just plain pig headedness!

These cases show how the most effective and simple trigger to catch potential cases could be one that flags up re attenders for the same problem for a complete rethink.

Regards
Jason

Jason Maude
Founder and CEO Isabel Healthcare
Tel: +44 1428 644886
Tel: +1 703 879 1890
www.isabelhealthcare.com<http://www.isabelhealthcare.com/>

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