Oximeters

Tom Benzoni benzonit at GMAIL.COM
Wed Jan 31 17:19:24 UTC 2018


I'd focus on the rampant, low-level, constantly-tolerated, worked-around
errors.
These create an atmosphere wherein errors are ok.
Given human behavior, "We're ok with doing small jobs badly; we want big
jobs done right."is the philosophy of failure.
Big jobs are based on small jobs.

It's also simple math: the result of any process cannot be more precise
than the least precise of its components. (There are myriad sayings:
weakest link, slowest runner, etc.)

Excellence built into the system percolates up; it cannot drizzle down.

tom

On Wed, Jan 31, 2018 at 9:58 AM, Robert Bell <rmsbell200 at yahoo.com> wrote:

> Dear Tom,
>
> Thanks - appreciate your illuminating comments/thoughts. If all errors,
> including diagnostic, are at times inter-related how does the diagnostic
> error movement move forward? Focus on the commonest problems/combinations
> or focus on those that produce the greatest damage? Or all. A massive big
> challenge.
>
> Rob
>
>
> Sent from my iPad
>
> On Jan 31, 2018, at 8:04 AM, Tom Benzoni <benzonit at gmail.com> wrote:
>
> Dr. Bell:
> It's not well known, and is a double tragedy.
> Clinicians get beat up over endangering a patient when there was no
> expectant danger.
> This has the odd effect of causing interventions when none is warranted
> and making people less cognitive/aware.
> The way I know it is not well known: Hospitals have pages long protocols
> for procedural sedation, many written, in my not-very-humble opinion, to
> protect margins, and i've never seen this error discussed. (Don't make them
> aware; it's a marker I use for situational awareness.)
>
> You've only scratched the surface of errors in BP readings. JAMA had a
> recent paper discussing med student errors in measurement.
> Fortunately, they didn't study attendings or nurses in practice; it would
> have been worse.
> And nowhere so I see awareness that automated cuffs do not measure BP;
> they find first turbulent flow (approximately MAP) then, using proprietary
> algorithms, calculate a systolic and diastolic. Find that method in AHA
> guidelines?
> I helped write, many years ago, the original ACEP guidelines to NOT
> normalize/treat asymptomatic BP elevations found in the ER. (Full-on
> discussion behind that one separately.)
>
> If we tolerate this low level error systematically, how can we expect to
> address the large/few errors?
> High frequency-low consequence errors are arguably of greater import than
> low frequency-high consequence ones; driving to the airport caries greater
> risk of death than the flight itself.
>
> tom
>
>
> On Tue, Jan 30, 2018 at 10:21 PM, Robert Bell <0000000296e45ec4-dmarc-
> request at list.improvediagnosis.org> wrote:
>
>> Thanks Tom,
>>
>> That is something to consider. How many HCPs know about that?
>>
>> What about, *Ipsilateral sphygmomanometer cuff - oximeter reading error*
>> !!
>>
>> And do not get me started on the frequency with which blood pressures are
>> taken with the wrong sphygmomanometer cuff size, and through clothing (some
>> times thick).
>>
>> I have in my postings to the list here always been interested in the
>> level of error in the things we do to help us with diagnoses. I strongly
>> believe that we need, to not only be improving our diagnostic abilities,
>> but also work to improve the errors of support tools at the same time. Both
>> need to be worked upon to get to our goal of significant reductions in
>> diagnostic error. That could be done with partnering with another society
>> or societies, more dedicated to standard errors, with time related goals to
>> help get there soon.
>>
>> Robert Bell
>>
>> On Tuesday, January 30, 2018, 2:57:56 PM MST, Tom Benzoni <
>> benzonit at GMAIL.COM> wrote:
>>
>>
>> Orthopedic changes do not effect them.
>> Skin thickness does not but we don't use these over callused areas.
>> They can read black skin. Melanin has a different spectral absorption.
>> Very cold extremities where the capillary beds are clamped down can cause
>> erroneous readings as can patients in extremis from end-stage myocardial
>> disease...but don't need a pulse ox there.
>> An interesting error source comes from blood pressure cuffs. Because the
>> cuffs are usually set to automatic, intermittent low readings occur not
>> from the patient but from temporary occlusion of the artery by the cuff if
>> on the ipsilateral arm. If you're not aware of this error source, you can
>> think the patient on whom you're doing a procedure is in trouble when
>> they're fine. And you might terminate the procedure or make an unnecessary
>> intervention on a well person.
>> What is that type of error?
>>
>> tom
>>
>> On Mon, Jan 29, 2018 at 11:49 PM, robert bell <
>> 0000000296e45ec4-dmarc-request at list.improvediagnosis.org> wrote:
>>
>> I was thinking also of the accuracy in elderly patients with
>> osteoarthritis, bent fingers, and soft skin versus hard thickened skin and
>> also the differences with different fingers.
>>
>> Yes, alarms are a problem.
>>
>> Rob Bell, M.D.
>> > On Jan 29, 2018, at 3:11 PM, Rory Jaffe <rjaffe at CHPSO.ORG> wrote:
>> >
>> > Interpretation is a big issue. Pulse oximetry is very insensitive to
>> hypoventilation when a patient is on supplemental O2. Also tends to have
>> lots of false alarms--the default limits are not very usable and ideally,
>> people would use patient-specific alarm limits.
>> >
>> > -----Original Message-----
>> > From: Grubenhoff, Joe [mailto:Joe.Grubenhoff@ CHILDRENSCOLORADO.ORG
>> <Joe.Grubenhoff at CHILDRENSCOLORADO.ORG>]
>> > Sent: Monday, January 29, 2018 8:55 AM
>> > To: IMPROVEDX at LIST. IMPROVEDIAGNOSIS.ORG
>> <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
>> > Subject: [No SPF Record] Re: [IMPROVEDX] Oximeters
>> >
>> > Pretty accurate in my experience - the problem may be in how this
>> single value is interpreted in the context of the whole clinical picture:
>> >
>> >
>> >
>> > Effect of Oxygen Desaturations on Subsequent Medical Visits in Infants
>> Discharged From the Emergency Department With Bronchiolitis.
>> >
>> > Principi T, Coates AL, Parkin PC, Stephens D, DaSilva Z, Schuh S.
>> >
>> > JAMA Pediatr. 2016 Jun 1;170(6):602-8. doi:
>> 10.1001/jamapediatrics.2016. 0114.
>> >
>> >
>> >
>> > Effect of oximetry on hospitalization in bronchiolitis: a randomized
>> clinical trial.
>> >
>> > Schuh S, Freedman S, Coates A, Allen U, Parkin PC, Stephens D, Ungar W,
>> DaSilva Z, Willan AR.
>> >
>> > JAMA. 2014 Aug 20;312(7):712-8. doi: 10.1001/jama.2014.8637.
>> >
>> >
>> >
>> >
>> >
>> > ´╗┐On 1/29/18, 09:49, "Robert Bell" <0000000296e45ec4-dmarc-
>> request at LIST.IMPROVEDIAGNOSIS. ORG
>> <0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG>> wrote:
>> >
>> >
>> >
>> >    How accurate are oximeters? Are the errors big enough to make wrong
>> decisions?
>> >
>> >
>> >
>> >    Rob Bell, M. D.
>> >
>> >
>> >
>> >    Sent from my iPad
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>>
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>> ------------------------------
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>> .IMPROVEDIAGNOSIS.ORG
>>
>> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
>> Medicine
>>
>> To learn more about SIDM visit:
>> http://www.improvediagnosis.org/
>>
>> ------------------------------
>>
>>
>> To unsubscribe from IMPROVEDX: click the following link:
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>> D1=IMPROVEDX&A=1 or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST
>> .IMPROVEDIAGNOSIS.ORG
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>> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
>> Medicine
>>
>> To learn more about SIDM visit:
>> http://www.improvediagnosis.org/
>
>
>






Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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