Outcomes and Errors

Bob Latino blatino at RELIABILITY.COM
Tue Apr 18 11:01:01 UTC 2017

Thanks Rob

I mentioned something along these lines months ago when trying to determine the scope of Dx error, from a practical standpoint.  I was seeking a means to identify what is known, versus unknown, relative to the occurrence of Dx error.  

Normally, what is known, is that if a Dx error leads to an undesirable outcome that 'is reportable' (hits a regulatory trigger that causes, harm, a fatality or an unacceptable near miss), it will have to be formally investigated.  Depending on the severity of the bad outcome, will determine if it will only be investigated internally or if there is a claim brought against a hospital, if external legal investigations will be conducted as well.

In these cases, the occurrence of a Dx error is known, because of the reporting of the bad outcome (either through the courts and/or a PSO).  So here, there would be a way to correlate known Dx errors that resulted in adverse outcomes.  These are what I consider actionable cases.  However, this population of cases, is probably a minority of the total population that exists.  There are likely many, many more Dx errors that do not cause harm (hit regulatory triggers) and therefore are not reported.  There are many more that are acceptable near misses and everyone is relieved they were 'good catches' and they got lucky, but they not required to be investigated or reported.  There are many others that are put into the 'complications' category and not deemed as errors, therefore they are not reported.

So for the Dx errors we know about (as described above), that were reported to some entity (either legal or safety), is there any source that aggregates all of these 'Dx error reportables' and breaks them down into sub-categories for deeper investigation based on manageable pieces of the Dx error pie?

In my experience of investigating such incidents, the systemic and human performance root causes you find for the 'reportables' will be very similar to the root causes for the ones that were not reported.  As long as the management systems are corrected, it should reduce or eliminate the failure paths that were in place as a result of flawed systems.  In other words, you are fixing and preventing many more failures than the one you are working on at the time.

This is what has perplexed me on this forum over the years.  I am not aware of the universally accepted definition, scope and magnitude of the Dx error problem?  I don't know how to solve something that I cannot get a handle on the actual problem.

Bob Latino

Robert J. Latino, CEO
Reliability Center, Inc.
blatino at reliability.com

-----Original Message-----
From: robert bell [mailto:0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG] 
Sent: Monday, April 17, 2017 1:38 AM
Subject: [IMPROVEDX] Outcomes and Errors

We lack extensive good data on all errors in medicine, including diagnostic.

Outcomes seem to be reported on occasions and the current issue of the May 2017 Consumer Reports (CR) has listings of Outcomes for cardiac surgery. 

CR  says that more than 1000 hospitals perform heart surgery. Half share their complication and mortality rates. There are tables which give regional ratings for hospitals submitting (South, Midwest, and West), and outcomes (survival, complications, developing a deep chest infection,suffering a stroke, kidney infection, etc. ranked as worse than expected, as expected, better than expected for both bypass surgery and aortic valve replacement. None were listed  as worse than expected.

This made me think and ask is there a correlation between outcomes and errors in medicine including diagnostic errors?

If there were more outcomes in various areas at a particular hospital could this correlate roughly with the errors in the hospital. With the possible message that if the outcomes are better in one or more areas of the hospital the total error rates will be lower due to higher general standards?

Is there any data from anywhere in the world that shows a correlation between outcomes and errors?

Rob Bell, M.D.

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