[No SPF Record] [IMPROVEDX] Culture

Mark Gusack gusackm at COMCAST.NET
Thu Jun 14 18:03:08 UTC 2018


Does there even have to be a study?!

 

My experience is replete with wrong diagnoses because the primary physician wouldn’t lower themselves to listen to anyone who was beneath them in the healthcare facility or who wasn’t “in their league” outside the facility.  And, this arrogance if often magnified by the tendency for human beings to internalize “things” and measure their self-worth against the validity of “those things” and so, cannot; will not, give in to rational thought applied to the facts when they threaten “those things”.

 

Mark Gusack

 

From: ROBERT M BELL <0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG> 
Sent: Thursday, June 14, 2018 12:51 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] [No SPF Record] [IMPROVEDX] Culture

 

Thanks Tom and Bob,

 

Is that the the lack of caution that comes with any degree of arrogance?

 

Does arrogance itself have a role in diagnostic error?

 

Has that ever been studied?

 

Does anyone know?

 

Rob Bell

 

 

 

 

On Jun 13, 2018, at 8:52 PM, Tom Benzoni <benzonit at GMAIL.COM <mailto:benzonit at GMAIL.COM> > wrote:

 

from  35+ years in the front lines of health care, this is for sure so.

And the arc is increasing.

I've recently moved from an area that always felt a bit inadequate to one that is self-assured.

The prior was much safer than the latter.

Ever hear the phrase "Fat, dumb and happy?"

 

tom benzoni

 

On Tue, Jun 12, 2018 at 12:26 PM Bob Latino <blatino at reliability.com <mailto:blatino at reliability.com> > wrote:

While this is referencing the Oil & Gas industry, there are some interesting stats related to the 'zero commitments' we were talking about earlier.  

 

"Unsurpirsingly, there is even a correlation between committing to a ‘zero accident’ vision on a project and killing more people. In a thoughtful recent study, British colleagues have demonstrated that projects subject to a ‘zero safety’ policy or program actually slightly increase the likelihood of having a serious life-changing accident or fatality (Sheratt & Dainty, 2017)."

 

Just an FYI.  

 

http://www.safetydifferently.com/oil-and-gas-safety-in-a-post-truth-world/#comment-3802

 

Robert J. Latino, CEO

Reliability Center, Inc.

1.800.457.0645

blatino at reliability.com <mailto:blatino at reliability.com> 

www.reliability.com <http://www.reliability.com/> 

 

From: Mark Graber [mailto:Mark.Graber at Improvediagnosis.org <mailto:Mark.Graber at Improvediagnosis.org> ] 
Sent: Tuesday, June 12, 2018 11:07 AM
To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG> >; Bob Latino <blatino at reliability.com <mailto:blatino at reliability.com> >
Subject: Re: [IMPROVEDX] [No SPF Record] [IMPROVEDX] Culture

 

That Decker article on ‘getting to zero’ is amazing – thanks for forwarding it Bob.


It was exactly this question, can we get to zero, that prompted my first-ever paper on diagnostic errors, arising from assertions at national meetings that we could completely eliminate serious safety events.   Don Berwick had it right: “The search for zero error rates is doomed from the start”.

 

Its also the wrong question; Better questions are:  How can we make progress, and how can we measure that?  And… now with the knowledge that unintended consequences will accompany whatever we do, how do we minimize those while maximizing accuracy, timeliness, and safety?  

 

Mark

  

Mark L Graber MD FACP

President, SIDM

Senior Fellow, RTI International

Professor Emeritus, Stony Brook University 

  

 

 

From: Bob Latino <blatino at RELIABILITY.COM <mailto:blatino at RELIABILITY.COM> >
Reply-To: Listserv ImproveDx <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG> >, Bob Latino <blatino at RELIABILITY.COM <mailto:blatino at RELIABILITY.COM> >
Date: Tuesday, June 12, 2018 at 10:03 AM
To: Listserv ImproveDx <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG> >
Subject: Re: [IMPROVEDX] [No SPF Record] [IMPROVEDX] Culture

 

Along this thread I thought this article may be of interest.  Declarations of 'zero' metrics, often has unintended consequences.  While on the surface they seem logical and admirable, they can suppress feedback loops for fear of affecting the zero metric (such as zero harm).  

 

The article is authored by noted safety researcher Sidney Dekker. 

 

Does this 'zero' mentality fall into the realm of how success in reducing Dx error is measured?  Is it applicable?

 

Regards

Bob Latino

 

Robert J. Latino, CEO

Reliability Center, Inc.

1.800.457.0645

blatino at reliability.com <mailto:blatino at reliability.com> 

www.reliability.com <http://www.reliability.com/> 

 

From: Rory Jaffe [mailto:rjaffe at CHPSO.ORG] 
Sent: Monday, June 11, 2018 3:04 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG> 
Subject: Re: [IMPROVEDX] [No SPF Record] [IMPROVEDX] Culture

 

The other studies show a reasonably strong link.

 

Some of the problems in making an overall assessment is that culture is very local, varying broadly from department to department within an organization. Within-organization variability is generally much higher than between-organization vulnerability on safety culture surveys. So studies that look at “culture” in the organization as a whole tend to have weaker results. The specific papers do show a decent link.

 

Also backing this conclusion is that, in other industries, this has been studied and there is a definite link between culture and safety.

 

I think there is a consensus in health care that there’s a link. Look at “to err is human” and subsequent publications from the National Academy of Medicine. These publications strongly presume that culture is important driver of safety.

 

 

From: ROBERT M BELL <rmsbell200 at yahoo.com <mailto:rmsbell200 at yahoo.com> > 
Sent: Monday, June 11, 2018 10:47 AM
To: Society to Improve Diagnosis in Medicine <IMPROVEDX at list.improvediagnosis.org <mailto:IMPROVEDX at list.improvediagnosis.org> >; Rory Jaffe <rjaffe at chpso.org <mailto:rjaffe at chpso.org> >
Subject: Re: [No SPF Record] [IMPROVEDX] Culture

 

Thanks Rory Jaffe,

 

Very kind.

 

Do you yourself have an overall opinion? I looked at the Weaver article which evaluated many studies. and, from my limited interpretation, that did not seem too positive.

 

Is there a general consensus amongst the medical profession as to whether culture is important in preventing errors?

 

Is to ERR more resistant to intervention than we think?

 

Rob Bell

 

 

On Jun 11, 2018, at 9:58 AM, Rory Jaffe <rjaffe at chpso.org <mailto:rjaffe at chpso.org> > wrote:

 

Weaver SJ, Lubomksi LH, Wilson RF, Pfoh ER, Martinez KA, Dy SM. Promoting a culture of safety as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158(5 Pt 2):369-374. doi:10.7326/0003-4819-158-5-201303051-00002.

 

 

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