BP Reading Accuracy
blatino at RELIABILITY.COM
Wed Feb 7 12:11:52 UTC 2018
I will offer a perspective from an outsider on how to explore how BP readings are not accurate and how they contribute to a bad outcome.
'Inaccurate BP readings' is not the problem needing to be solved. Not having accurate BP readings is likely a contributing factor to causing an undesirable outcome to occur (e.g. - harm and/or high risk near miss). That is what catches our eye, when a bad outcome occurs, not the questioning of the accuracy of a BP reading when nothing goes wrong.
By asking 'How Could' past the Mode (M) level, we are seeking to break the problem down into digestible chunks. How could a BP related condition not be detected?
1. Equipment Related
2. Human Related
3. Admin Related
Now I am not a clinician and am not stating these hypotheses as being all inclusive (or even accurate), that is for you professionals to decide. I offer this example to show how to use logical deductive reasoning to think through why things go wrong.
1. Something could be wrong with the equipment (the stethoscope in this case). How could something be wrong with the equipment?
2. It could be related to who is using the stethoscope. Let's assume the equipment is fine, but the interpretation is not accurate. How could this be?
3. It could be Admin related. Let's assume the equipment is fine, the interpretation is fine, but the conveying of the accurate results falls in an administrative crack before reaching the decision-maker. How could that be?
This is obviously not complete, but I just want to show the questioning sequence that other industries use to reason out why bad things happen. Each of these blocks have a 'verification log' that cites evidence to back up whether the hypotheses proved to be true or not, who collected it and when it was collected.
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Robert J. Latino, CEO
Reliability Center, Inc.
blatino at reliability.com
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