Diagnostic error - cause or outcome, event or process

Bob Latino blatino at RELIABILITY.COM
Wed Apr 12 11:26:48 UTC 2017


Thanks Pat

I am in total agreement with your post.  I am not a cognitive scientist by far, but I follow many of their works (S. Dekker, J. Reason, j. Rasmussen, E. Hollnagel and T. Conklin) and incorporate the principles of their work into 'RCA' as we apply it (our brand is called PROACT).

I am speaking soon to a nuclear forum focusing on human performance.  Sidney Dekker and Todd Conklin will also share the program with me (or I with them:-).  Both of these well-known gentlemen conduct research in the human performance arenas.  However, they are outspoken critics of RCA.  I can see why as 'RCA' is a widely used, useless term these days.  Whatever approach anyone uses to solve problems, they will call it RCA, even if it is trial-and-error or 5-Whys.

That is my purpose at this venue, to define what 'RCA' means to me and my firm, having been applying it successfully for the past 43 years.  My paper is entitled, 'What's Wrong With RCA?'.  It is intended to defeat the general myths about RCA from these researcher's writings. I think we simply define RCA differently and I hope to bridge that gaps with facts at this conference.  The two approaches complement and do not contradict nor compete with each other.

You are correct that most lead analysts/investigators in the field will not understand the cognitive sciences, therefore they will likely not be able to ask the decision-maker the right questions.  This does not make the 'process' less applicable, just those conducting the process will make it less effective.  There is a WIDE gap between the research/academic communities in this space, and those that actually apply the RCA processes on the front-lines.

RCA analyzes individual undesirable outcomes. It has the potential to proactively analyze successes as well, but that is another paper. Given this narrow scope of an RCA, its sole purpose is to understand the decisions made that triggered a bad outcome in an individual case.  This is where all of the cognitive research comes into play with a knowledgeable and experienced lead investigator conducting the interviews. I believe, from reading the experience on this forum, that such expertise exists here to develop such guidelines.  I can tell you that general RCA analyst's in the HC space will not possess this talent.

I further believe that an immediate step forward, would be to construct and Dx Error RCA template, which graphically expresses the various cause-and-effect possibilities to consider (initially start with the most common), when doing an RCA drill down on a Dx error. I have attached a sample that I have posted in the past for your review.  We maintain many such RCA template libraries for various outcome types in various industries (and use in our software for querying).  This one, is one of many others we have, and this one is certainly not all--inclusive.  However, as a guide, it does help RCA lead investigators consider hypotheses that they normally would not, so it is expanding their thinking and pushing them to explore broader possibilities that affect decision-making.

I believe a 'deliverable' from this group, that could be used now, would be a job aid such as the attached, specifically for cases involving Dx error.  Such a job aid along with an interviewing guideline, would be immensely helpful in the field right now.

From the research standpoint, RCA is but a single data point.  I have heard mention of Common Cause Analysis (CCA) on this forum, which again means different things to different people.  In my world, CCA is the ability to effectively trend across an accurate and comprehensive RCA database.  For this to happen, logical coding has to occur in order to have your desired cause categories come together.  This simply means that identified Latent Root Causes using free-form text, but be dropped into logically coded, cause category buckets.  That is another topic which he have dealt with and resolved from a technology standpoint, but the point is that RCA's feed into a DB (hopefully a national DB) and from there Trending can be done and statistics developed.  PSO's around the country accept (and protect) these submitted RCA's to The Joint Commission (TJV) and DNV.  These would be the ideal sources to be able to nationally trend such Dx cause categories.  I think ECRI would be a potential partner to work with to explore this possibility.

From the application world, with the talent in this group, I would think it would be easy to come up with an initial Dx Error job aid like attached and an associated interviewing guideline document.  Of course it would not be complete (such libraries never are and never will be), but it will be leaps and bounds better than what analysts are doing in the field right now.  I am in the trenches and say this with confidence.

Thanks to Peter Elias for having a candid discussion with me off-line and seeing enough value in my short blog post, to post it here for debate and discussion.

Robert J. Latino, CEO
Reliability Center, Inc.
1.800.457.0645
blatino at reliability.com
www.reliability.com
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From: Pat Croskerry [mailto:croskerry at EASTLINK.CA]
Sent: Tuesday, April 11, 2017 8:11 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] Diagnostic error - cause or outcome, event or process

Thanks Peter and for your earlier contributions to this discussion.
Bob Latino’s blog raises a number of important issues.
The para towards the end that begins: When talking to the decision maker… gives a good feel for the complexity of the diagnostic process, especially if one is attempting a cognitive RCA.
Individual factors that influence decision making are multifarious and Bob mentions some of the main ones – others are age, gender, and personality of the decision maker.

Cognition is invisible for the most part, and inferences are vulnerable to hindsight and outcome bias.
However, I don’t think the problem is insurmountable.
The cognitive scientists have been busy for the last few years on how we make decisions.
One of the major concepts to emerge has been the notion of individual rationality – largely missing from extant RCAs.

  1.  In terms of decision making, rationality is now considered superlative to all else – it trumps critical thinking and intelligence.
  2.  It is no longer seen as binomial i.e. that someone is either rational or not, but rather is distributed, just like intelligence – thus some folk will be more rational than others (this doesn’t necessarily mean smarter )
  3.  Rationality can now be measured on appropriate tests – it is possible to calculate an RQ score (rationality quotient) – consider including it on medical school admissions?
  4.  Importantly, we know the main sources of rationality failure – they are (a ) cognitive miserliness (tendencies to treat information superficially or with insufficient effort), (b) mindware gaps (missing bits of critical information, failures in probability reasoning etc),  and (c) mindware contamination – logical failures in reasoning, cognitive biases, eccentric reasoning.

If people understood these three main sources of cognitive failure and how to recognise them, as well some of the other major factors that influence individual cognition, and were mindful of hindsight and outcome bias, a reasonable stab at a cognitive RCA might be possible.
Pat Croskerry


From: Elias Peter [mailto:pheski69 at GMAIL.COM]
Sent: April 11, 2017 9:34 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: [IMPROVEDX] Diagnostic error - cause or outcome, event or process

Bob Latino wrote an interesting blog post about error here:

https://www.linkedin.com/pulse/error-cause-outcome-bob-latino?published=t

(Disclaimer - he included a comment I provided as feedback when I read it.)

I think it is very pertinent to the discussions this group has about the nature of diagnostic error, and I’d be interested in hearing what the group thinks. I’ll hold off on contributing my thoughts to avoid framing the conversation.


Peter Elias, MD

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