Computer analysis of probable Root Cause/Contributing Cause(s) of preventable patient deaths using elecctronic medical records.

John Brush jebrush at ME.COM
Tue Mar 7 13:13:46 UTC 2017

I think this post by David Woods is really important. This systems approach was brought to health care by Don Berwick and others.
I also think that we could bring a systems approach to our own thinking. Rather than thinking back and blaming ourselves for error (a flawed hindsight approach), we should think prospectively about how we can organize our thinking, develop good thinking habits, use reminder systems, and calibrate our intuition using simple tools like likelihood ratios. This is what I tried to emphasize in my book.
John Brush

John E. Brush, Jr., M.D., FACC
Professor of Medicine
Eastern Virginia Medical School
Sentara Cardiology Specialists
844 Kempsville Road, Suite 204
Norfolk, VA 23502
Cell: 757-477-1990
jebrush at

On Mar 6, 2017, at 11:29 AM, Woods, David <woods.2 at OSU.EDU> wrote:

The question posed provides an opportunity to recalibrate some of the discussions about diagnosis.   At the beginning of the patient safety movement,  two of the three  basic values we articulated were:  to move beyond blame and to adopt a systems approach.  The discussion has surfaced the desire to have a computer automatically (or to have a computer aided mechanism) to trace back from adverse event to cause.  This falls into the hindsight bias trap which has plagued and undermine the ability to learn after adverse events.  Tracing backwards from outcome in search of cause guarantees hindsight bias, and hindsight bias will lead to oversimplifications. The oversimplifications will inevitably lead to a component not a systems view and will focus on people and blame. This is laid out in the book Behind Human Error (originally 1994 / 2nd edition 2010), and overcoming hindsight bias was one of the important messages during those early days and the rise of the patient safety movement 1995 to 2000.  

The key is to trace forward based on the nature of cues, possibilities, uncertainties, expectations, norms, work activities, etc.  This is laid out in Behind Human Error and then in the later Field Guide to Human Error Investigation by Dekker.   

Today  there are two major threads in safety related to the original work on escaping the hindsight bias. One  is captured in the phrase — "the difference between work as imagined and work as done.”  This phrase is used to highlight that improving safety should focus on what usually goes right and what people do in order to make things work. For example blameless postmortems are being used by many capture a much wider range of information about how the system normally works the difficulties it faces pressures that operates under and how  the system really works.  Breakdowns and incidents provide opportunities to learn about how the system really works so that I can be modified in ways  the function better given the real pressures and resource limitations. The second relates to the failure to truly see systemic factors rather than faulty components - usually people. As one health care manager said, “ system, what’s a system? I can’t blame a system.”  This tendency to adopt a systems approach rhetorically, but to continue to analyze adverse events is due to component breakdowns is widespread across industries (or the systems factors become vague category labels like communication). As a result, variety of techniques of been developed (e.g., STAMP and FRAM  and others) and are being used to try to facilitate true systems thinking especially as part of proactive safety management.  A good resource is the PreAccident Podcast series by Todd Conklin <>

 The basic points are:
~ to remind people about the contamination that comes from the hindsight bias, 
~ tracing backwards from known outcome guarantees hindsight bias and oversimplifications which block learning.

The second part of the comment is — how can computers help us understand diagnostic process looking forward, not backward, and provide insight about the difficulties and vulnerabilities given the wide variety and diversity of clinical situations that can be included under the general label of diagnosis.   This is a quite interesting topic and one that requires weeding away some of the assumptions and misunderstandings that are mixed up in the discussions about improving diagnosis in health care.  But that is for another post.


David Woods
Releasing the Adaptive Power of Human Systems

follow @ddwoods2 <>

Department of Integrated Systems Engineering 
The Ohio State University

Past-President in
Resilience Engineering Association
Human Factors and Ergonomics Society

7th Biennial International Symposium on Resilience Engineering
Liège Belgium, June 26-29, 2017

woods.2 at osu dot edu

SNAFU Catchers Consortium <>

keynote on autonomy and people see
part 1: <>   part 2: <>  part 3: <>

keynotes on resilience and complexity see <>
or <>

> On Mar 4, 2017, at 4:52 PM, Phillip Benton <0000000697ec7b18-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG <mailto:0000000697ec7b18-dmarc-request at>> wrote:
> Jason,
> As a physician-attorney now devoting all of my remaining time to improving medical quality by decreasing medical error, I applaud your great and continuing efforts.
> I am exploring the possibility of creating a system that reverse engineers from decisions on Dx and Rx and would like your thoughts: If we know the adverse event [patient death after 6 days illness with undiagnosed (until autopsy) septic peritonitis from diverticulitis with occult rupture] is there any computer program in existence or under development that can input the recorded clinical and pathologic facts to deduce a probability hierarchy of medical errors that would have led to this patients death? In effect, is there software to do probable
> 'root-cause analysis' based strictly upon the digitized medical record (H&P, imaging, labs, consultant opinions, path reports)?
> She was first misdiagnosed as "constipation" on the first ER visit for severe abdominal pain, then again misdiagnosed as "atypical cardiac pain" on ER visit 3 days later. Acute abdomen "signs" were present but not classic, not uncommon for a 72 YO with an aging immune system.  She was admitted and had negative cardiac consultation but no further diagnostic studies, then died 23 hours after admission with cardiovascular collapse from undiagnosed sepsis.
> If this type computer retro-analysis were possible, the next step would be to investigate to confirm and then to correct the human and systems errors. Of course an experienced physician(s) has to put it all into context at the end, but just trying to piece together an exact chronology is very difficult, even for top (Harvard & Yale) reviewing medical experts, with our new  electronic hospital records systems. Could 'Watson' or 'Isabel' not do it more quickly?
> Thanks,  PGB 
> Phillip Benton, MD, JD
> Atlanta Medical Center
> pgbentonmd at <mailto:pgbentonmd at>
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