What comes first?
blatino at RELIABILITY.COM
Mon Mar 13 11:16:39 UTC 2017
Years ago I was an RCA team leader on a project funded by CMS called the 'Fistula First Breakthrough Initiative' or FFBI. The end goal was to raise the national use of Fistulas for primary access to around 61% (if I recall correctly).
I've attached the draft summary of the analysis effort which is not related to any singular case and contains no PHI. My purpose in showing this summary is to demonstrate the discipline of the analysis with the analysis team, and to see if the structure would be applicable to trying to break down the issue of Dx error into digestible 'chunks' as we did in the FFBI case.
To me, this falls in line with the suggestions by Rob Bell and Kyle Hueth below.
While I have stated this in the past, Dx Error is not the 'Problem' or the 'Root Cause'. Dx error is a trigger that sets off a path of observable cause-and-effect sequences, that likely end in a bad outcome or an unacceptable near miss (the Problem). The root causes follow the other direction and seek to understand why the person making the diagnosis, felt the decision was correct at the time. This is what Rob and Kyle are talking about below. What information was put together in the decision-maker's mind, to come to that conclusion/diagnosis?
But, to me, this comes full circle to the discussion we had weeks ago about 'What is the definition of a Dx error?'. In order to do an exhaustive analysis on such a complex issue, it first has to be defined in a logical manner and then broken down into manageable chunks. After that is determined, then each of the 'chunks' can be explored to their micro levels to get into the reasoning for such decisions. Once such info is captured in such a cause-and-effect structure using software tables, then it is just a matter of applying existing technologies to create knowledge management systems which can best manipulate the content and instantly put the necessary content (queried) at the fingertips of those that need it.
I am not the 'clinical content' person, I'm just a facilitator that has considerable experience pulling such information from the Subject Matter Experts (SME's) in a disciplined and logical manner. Here is just a structure sample from a novice, to show what I mean by breaking down a complex issue like Dx error, which will mean different things to different people.
[cid:image002.jpg at 01D29BC9.9E951D70]
Followed (only as example) by drilling down on 'Delayed Diagnosis' and asking 'How Could?' the previous node occur? This is not complete by far as the drilling would continue beneath where I stopped to further understand 'why someone in such a position may have inadequate knowledge to make an appropriate decision under the circumstances?"
[cid:image006.png at 01D29BC9.9E951D70]
These are just ideas (and not comprehensive at all) for how to properly define the problem and logically break it down to uncover physical, human and latent root causes. All of the research about cognitive biases would fall below the 'Human Roots' (decision errors) and into the cause category of 'Latent or Systematic' root causes which influence decision errors.
FYI - as a legend:
E = Event
M = Mode
H = Hypothesis
# in Node = Confidence Factor (scale of 0 to 5 based on strength of evidence)
Robert J. Latino, CEO
Reliability Center, Inc.
blatino at reliability.com
From: Hueth, Kyle D. [mailto:kyle.hueth at ARUPLAB.COM]
Sent: Sunday, March 12, 2017 6:55 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] What comes first?
I completely agree! The common examples you list really highlight the impact these inaccuracies could potentially have on the development of a working diagnosis for a large number of patients. I am a consultant that specializes in appropriate utilization of laboratory testing and my experience has taught me that, while the analytical accuracy of testing has drastically improved, the accuracy in ordering the right test and at the right time has decreased. This isn't surprising considering the rapidly evolving test menu and the subpar functionality of the EHR when it comes to ordering labs and displaying results. I feel addressing these identifiable sources of error are the logical first steps towards reducing diagnostic error. AI solutions won't help solve this problem if the inputs are inaccurate.
Kyle Dean Hueth, MLS(ASCP)
Sent from my iPad
On Mar 12, 2017, at 14:06, robert bell <0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG<mailto:0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG<mailto:0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG%3cmailto:0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG>>> wrote:
I have often wondered whether we should at the same time as we work towards more accurate diagnoses, whether we should first sort out all the errors that we blindly seem to accept in medicine.
* The inaccuracy of all the tests we use. Including routine lab tests and radiological evaluations.
* The inaccuracy of the stethoscope with HCPs, particularly those with hearing losses and lack of experience.
* The need for two forms of identification for each patient.
* Taking a blood pressure measurement over differing layers of clothes.
* Weighing someone at the time of an office visit with differing weights of clothes and items being carried.
* Taking three blood pressure measurements on separate days after resting to diagnose hypertension. It is said that there are many on hypertensive medicine who need not be.
* And I am sure there are 100s more to add to this small list.
Perhaps ally with a Society that can take on this task, or even do it ourselves? Triage the most important and, ? issue a report, do research if necessary, ? start tomorrow.
? A FIRST TIDY UP MEDICINE PROGRAM - that should help with diagnoses.
Rob Bell, M.D.
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