CMS response to cancer misdiagnoses due to lab errors

Mark Graber Mark.Graber at IMPROVEDIAGNOSIS.ORG
Wed Mar 21 17:29:12 UTC 2018


Brian makes an excellent point here.  The news is ‘juicy’ but the learning is nil.
We’ve discussed this before in regard to malpractice settlements – the non-disclosure clauses preclude sharing and learning.

It would be amazing if CMS, TJC and other bodies that receive detailed analyses of accidents and near misses could turn these into learning opportunities more effectively.  The sentinel event alerts that the TJC publishes are a wonderful example, but we need many more notices like this.

Mark


Mark L Graber MD FACP
President, SIDM
Senior Fellow, RTI International
Professor Emeritus, Stony Brook University




From: "Jackson, Brian" <brian.jackson at ARUPLAB.COM>
Reply-To: Listserv ImproveDx <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>, "Jackson, Brian" <brian.jackson at ARUPLAB.COM>
Date: Tuesday, March 20, 2018 at 12:26 PM
To: Listserv ImproveDx <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] CMS response to cancer misdiagnoses due to lab errors

Speaking as a pathologist:  There are a number of possible root causes here.  The news story gave very little detail, but did indicate that the hospital is blaming one individual who is no longer part of the lab.  It’s certainly possible that one person’s negligence could have caused these errors in ways that would have been difficult for others to detect.  For example, a pathologist or pathologist’s assistant or pathology resident could switch samples or containers or labels during initial processing of the biopsies.  Or a histotechnologist could do the same thing when making the microscope slides.  It’s also possible that it could have been something that would have been caught by a better quality management system.  But maybe not.  Given such limited info, it’s just really impossible to say.

In an ideal world, the post-investigation details of a case like this would be made public for the rest of us to learn from.  Unfortunately, accreditation agencies (and I’m using the word broadly to include CMS) don’t put enough emphasis on post-problem transparency and education.  We’re often left to rely on whatever local journalists can discover and publish.  Which these days is usually little to none, given the decimation of local investigative journalism thanks to the business dynamics of the internet.

--Brian Jackson

From: Bob Latino [mailto:blatino at RELIABILITY.COM]
Sent: Tuesday, March 20, 2018 10:17 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] CMS response to cancer misdiagnoses due to lab errors

Thanks Peggy.

The hospital corrective action plan is weak (based on the one paragraph explanation they provided).

Where was the management oversight to detect all of those 'now visible' deficiencies in qualifications, equipment deficiencies and less-than-adequate (LTA) quality processes?

Why didn't the staff who worked daily in the presence of these obvious deficiencies, feel comfortable to speak up?  OR, did they speak up and weren't heard (or listened to)?

Their response is the typical 'retrain and revise procedures' approach while overlooking the systemic deficiencies, restraining cultural paradigms and sociotechnical factors, that permitted the 'drift' to occur in the degradation of standards. This is often the case when seeking to be compliant versus safe.

How come most of the ~6000 hospitals in the U.S. are accredited yet the medical error death rate continues to climb (since magnifying glass was focused on the topic of patient safety in the 1999 IOM report)?

Bob

Robert J. Latino, CEO
Reliability Center, Inc.
1.800.457.0645
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From: Peggy Zuckerman [mailto:peggyzuckerman at GMAIL.COM]
Sent: Tuesday, March 20, 2018 11:07 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: [IMPROVEDX] CMS response to cancer misdiagnoses due to lab errors

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