Beyond biases?

Edward Winslow edbjwinslow at GMAIL.COM
Tue Feb 14 23:31:43 UTC 2017


On the other hand, communication is supposed to be an interaction with at
least two people being responsible for communication: 1) the person
initiating the discussion who has a responsibility to ensure that she/he is
understood and 2) the person receiving the communication to ensure that
he/she has understood what person 1 really meant.

This is often encouraged by each party encouraging repeating their
understanding of the discussion.

Poor communication is likely multi factoral! Culture of openess and
decreased autocratic behavior will improve it.

Remember: "Culture eats Strategy for Breakfast ..." (Peter Drucker)

On Thu, Feb 9, 2017 at 2:44 PM, Bob Latino <blatino at reliability.com> wrote:

> "Miscommunication between MD and RN?  How do you prevent this?"
>
>
>
> I have always looked at communication as a system (as I look at everything
> as a system):
>
>
>
> *The Communicator (Deliverer) > the Message (Delivery) > The Recipient
> (Delivered To)*
>
>
>
> So when a miscommunication is identified , there are certain things we
> look for based on the system:
>
>
>
> Were there appropriate communication protocols/systems in place to
> accommodate the situation?
>
> 1.       If NO, why not?
>
> a.       If a condition existed that should have had a protocol in place
> to handle it, how was communication actually handled in the absence of such
> structure?  Usually 'practices' evolve that people become complacent with.
> This is until new people enter the picture and are not familiar with the
> evolved practices. Then a Sentinel Event type of failure occurs and things
> like this deficiency come out in the investigation.
>
> b.      From a management oversight standpoint, if a protocol was
> necessary and didn't exist, why didn't such oversight personnel recognize
> this need, and fill the void?
>
> c.       Why did those who needed a standardized communication system say
> anything?
>
> 2.       If YES, why wasn't it followed? Hypotheses could be:
>
> a.       Existing protocol was inadequate or insufficient; conscious
> decision to not follow protocol.
>
>                                                                i.      How
> did the existing protocols devolve into unacceptability, without being
> recognized?
>
>                                                              ii.      Was
> there an annual review of the appropriateness of such protocols?
>
> b.      'Normalization of Deviance' evolved - whenever one is
> time-pressured they oftentimes take a short cut.  When there is no negative
> consequence for taking the short cut, then the initial standard is eroded.
> When this cycle continually reiterates, the gap between the evolved
> practice and the initial standard becomes dangerous.  Usually it takes a
> catastrophe to reset to the original standard (after the hindsight
> investigation).  Challenger and Columbia are classic cases on this
> phenomenon.
>
> c.       In these cases we have to look at why people become comfortable
> with not following the protocols in place?
>
>                                                                i.      In
> many cases people of certain prominence do not follow the rules because
> they know they will not be challenged.  That is a big problem:-)  This
> delves into Just Culture issues related to why this paradigm exists.
>
>                                                              ii.      In
> other cases, we watch other people's bad behavior and thus believe if it is
> OK for them, it's OK for me.
>
>                                                             iii.      The
> command-and-control nature of HC often plays a role as subordinates feel it
> is career-limiting to challenge their superior on the following of the
> rules.  Again, a Just Culture issue arises as to why that is the case.
>
>
>
> The first thing we look for was there a communication model in place to
> follow? If there wasn't we have to determine why there wasn't.  If there
> was, we have to determine why people deviated from the model.
>
>
>
> Of course this is not inclusive, but it should make my point as to how we
> handle miscommunications in the course of an RCA, by drilling down past the
> decision-maker and into the systems influencing the decisions.
>
>
>
> A true HRO environment would see all of this as preventable.  This is
> because HRO's are inherently proactive by their nature.  They identify,
> prioritize and focus on unacceptable risks versus becoming better, quicker
> responders.  All of the above issues are foreseeable.
>
>
>
> I say this from experience, as my firm was formerly the Corporate R&D
> Reliability Engineering Group for Allied Chemical (more commonly known as
> Honeywell today) *in 1972*.  While HRO has become a buzzword in HC today,
> we actually set up the first global Reliability Department nearly 50 years
> ago.  Here is a pic of the first Reliability Engineering team....looks like
> the pic of the original developers at Microsoft:-)
>
>
>
>
>
> Thanks for your patience?
>
>
>
> *Robert J. Latino, CEO*
>
> Reliability Center, Inc.
>
> 1.800.457.0645 <(800)%20457-0645>
>
> blatino at reliability.com
>
> www.reliability.com
>
> [image: 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:* Kohn, Michael [mailto:Michael.Kohn at UCSF.EDU]
> *Sent:* Thursday, February 09, 2017 2:46 PM
> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> *Subject:* Re: [IMPROVEDX] Beyond biases?
>
>
>
> ACE inhibitor-related angioedema is a common presentation in the Emergency
> Department.  Medications are the first thing we ask when someone presents
> with lip or tongue swelling, or a feeling like the throat is closing,
> always looking for enalapril, lisinopril, etc.  I have intubated a few
> patients and done one surgical airway for this problem. That said, I
> recently had a patient with ill-defined respiratory difficulty.  No ACE
> inhibitor on his med list, but I didn't ask him (despite my statement above
> that I always ask).  It turns out he was on one.  Another MD was smart
> enough to ask him.
>
>
>
> It is not clear that this death (the case below) was a diagnostic error.
> This may fall into another category of error.  Miscommunication between MD
> and RN?  How do you prevent this?
>
>
>
> Michael
>
>
>
> Michael A. Kohn, MD, MPP
>
> Associate Professor
>
> Epidemiology and Biostatistics
>
> (Email created using voice recognition.  Please excuse transcription
> errors.)
> ------------------------------
>
> *From:* Thomas Benzoni [benzonit at GMAIL.COM]
> *Sent:* Thursday, February 09, 2017 10:22 AM
> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> *Subject:* Re: [IMPROVEDX] Beyond biases?
>
> Had on one of these last night.
>
> Someone had given him an EpiPen.
>
> This is not an allergic reaction but a manifestation of induced compliment
> deficiency.
>
> (HAE is the natural analog.)
>
>
>
> I frequently see the error of calling this reaction an allergy.
>
>
>
> I wonder if this might not be a fruitful construct to find about error,
> using the technique root cause analysis. (Fully document the occurrence,
> remove the particulars, see the skeleton.)
>
>
>
> To do this, you'd have to really commit to Just Culture. This is a much
> bigger hurdle than commonly appreciated and may represent the key.
>
>
>
> tom
>
>
>
> Fearing no insult, asking for no crown, receive with indifference both
> flattery and slander, and do not argue with a fool. -Aleksandr Pushkin,
> poet, novelist, and playwright (6 Jun 1799-1837)
>
>
> On Feb 9, 2017, at 6:06, Bob Latino <blatino at RELIABILITY.COM> wrote:
>
> 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 <(800)%20457-0645>
>
> blatino at reliability.com
>
> www.reliability.com
>
> <image001.jpg>
> <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 <ReganE at NJHEALTH.ORG>]
>
> *Sent:* Wednesday, February 08, 2017 8:51 PM
> *To:* 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>
> *Reply-To: *"IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG" <IMPROVEDX at LIST.
> IMPROVEDIAGNOSIS.ORG>, Jason Maude <jason.maude at ISABELHEALTHCARE.COM>
> *Date: *Tuesday, February 7, 2017 at 12:22 PM
> *To: *"IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG" <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 <+44%201428%20644886>
> Tel: +1 703 879 1890 <(703)%20879-1890>
> www.isabelhealthcare.com
>
>
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-- 
*Edward B, J. Winslow, MD, MBA*
Home 847 256-2475; Mobile 847 508-1442
edbjwinslow at gmail.com
winslowmedical.com

"The only thing new in the world is the history that you don't know"
       Harry S. Truman, 33rd President of US (1945-1953)


"... it can be argued that underinvestment in assessing the past is likely
to
lead to faulty estimates and erroneous prescriptions for future action."
        Eli Ginzberg, 1997






Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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