[No SPF Record] Re: [IMPROVEDX] Transfers/referrals

robert bell rmsbell200 at YAHOO.COM
Tue Jan 9 21:19:31 UTC 2018


Bob brings up a good point.

If we cannot easily show accurately how to prevent most standard and diagnostic errors, perhaps there could be a way to analyze the big life threatening/serious errors (bad outcomes) with eventual reports to all hospitals on how to best prevent.

Ot something like that.  For example I have not personally seen any recommendations to reduce the 600 or so OR fires each year. Have there been reports? They should be out there.

Could something like that be sensibly done 

Rob Bell, M.D.
> On Jan 8, 2018, at 4:19 PM, Bob Latino <blatino at RELIABILITY.COM> wrote:
> 
> Is there any data on reported bad outcomes (i.e. - sentinel events, serious safety events) that involved diagnosis error as a validated cause and/or contributing factor?
> 
> Sent from my iPhone
> 
> On Jan 8, 2018, at 6:13 PM, Harry Burke <harry.burke at GMAIL.COM <mailto:harry.burke at GMAIL.COM>> wrote:
> 
>> The incidence depends on how you define diagnostic errors and how you detect diagnostic errors.
>> 
>> Sent from my iPhone
>> 
>> On Jan 8, 2018, at 5:43 PM, Rory Jaffe <rjaffe at CHPSO.ORG <mailto:rjaffe at CHPSO.ORG>> wrote:
>> 
>>> There are no reliable estimates of the incidence of diagnostic errors.
>>>  
>>> Rory
>>>  
>>> From: robert bell [mailto:0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG <mailto:0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG>] 
>>> Sent: Sunday, January 07, 2018 10:58 AM
>>> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
>>> Subject: [No SPF Record] Re: [IMPROVEDX] Transfers/referrals
>>>  
>>> Dear all,
>>>  
>>> It is said that of the errors in medicine two thirds are standard errors while one third are diagnostic (does anyone know where those figures came from?).
>>>  
>>> It this is true then the next question would seem to be what is the impact of standard errors (from computers, hand offs, medication, laboratory and radiology errors, etc., etc.) on diagnostic errors. Is it a  small of large figure? Are there  any estimates?
>>>  
>>> Then the question arises should we as a community/organization be dealing in someway with all errors and not solely diagnostic. 
>>>  
>>> In fact, if the standard errors significantly effect diagnoses, will we be able to easily prove that any diagnostic approach is worthwhile?
>>>  
>>> Will historical analyses work? How would you compensate for standard error rates being different in different hospitals and HC facilities.
>>>  
>>> Do we need to know the level of effect of standard errors on diagnostic errors in different facilities? 
>>>  
>>> Robert Bell, M.D.  
>>>  
>>> 
>>> 
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Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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