Hindsight bias issues

Peggy Zuckerman peggyzuckerman at GMAIL.COM
Thu Nov 8 23:45:27 UTC 2018


RE "poor choices" and Tom Westover's thought or hope that physicians make
the best, most prudent decision at the time with the data at hand, and then
alter that decision when new information comes in.  Sadly, I remember Mark
Graber in about 2013 at the first SIDM conference I attended talking about
the great difficulty that doctors had in changing their conclusions, even
as new information came to light.  The anchoring bias did just that, and
the new data was usually explained away as an anomaly.  Stunning to me as a
patient, as that was apparently what had happened to me.  My 'tiny,
scabbed-over stomach ulcer" (to account for a severe anemia) which was not
found by the pathologist, nor with any H. pylori, led to two more
endoscopies. The "ulcer" then became 'confirmatory' striations, with
ongoing and then expanded Protonix, more iron, etc, etc until a new
diagnosis emerged.  That was to be cirrhosis of the liver, requiring an
ultrasound prior to a liver biopsy.  The US revealed a 10cm tumor and a
subsequent CT revealed 100s of tiny lung mets.

I shall always assume that he never read the pathology report, nor the
advice of the admitting ER doctor, who recommended I see a hematologist.
As a patient, I never received those two critical documents until I began
to seek the reason for the lack of a relatively prompt diagnosis.  Had I
see those documents, I certainly would have asked, "What else can cause
severe anemia?" or simply "What else can it be?".

Thus my push that all patients get ALL the records immediately upon their
production, and prior to their receipt by the doctor.  Do we need to hear
more stories of lost results, often due to "Don't call us; we'll call you."

Happy to report that was 14 years ago.  Naturally it hasn't changed that
much.
www.peggyRCC.com


On Thu, Nov 8, 2018 at 3:15 PM Thomas Westover <
000000040134e744-dmarc-request at list.improvediagnosis.org> wrote:

> I can’t resist ...
>
> It’s quite ironic that you said >
>
>  “as in all bad outcomes, a POOR choice was made at some point...”
>
> Laura Zwaan recently showed very eloquently that hindsight bias alters our
> perception of whether an error has occurred during the decision making
> process (Zwaan BMJQS 2017)
>
> Ie. if you “know” that an adverse outcome has occurred, you are much more
> likely to conclude that erroneous decision making occurred than if you
> “know” that a good outcome occurred (holding the decision making process
> constant....)
>
> I hope I quoted you correctly Laura :)
>
> Physicians don’t generally make “poor choices”: they make the “best, most
> prudent” decision based on the available evidence at THAT particular point
> in time
>
> It’s only when further time passes, and MORE evidence/data become
> available , that we realize that the initial decision was “incorrect “
>
> This dynamic process is at the heart of why “inappropriate” decisions are
> made and why “dx errors” occur
>
> I believe we should  re-classify “dx errors” as dx variability or some
> other such term that reflects the inherent uncertainty  that occurs during
> dx decision making especially during the analysis of complex cases
>
> As you note , one should be cautious in applying retrospective “after the
> fact” conclusions to prospective decision making...
>
> Respectfully
> Tom
>
> Thomas Westover MD
> Cooper Medical School
> Camden NJ
>
>
> Sent from my iPhone
>
> On Nov 8, 2018, at 1:58 PM, Bob Latino <blatino at RELIABILITY.COM> wrote:
>
> Agreed.
>
>
>
> As I’ve stated many times on this forum, I see ‘Dx Error’ as a huge cause
> category.  By itself it is not a bad outcome or near miss where it would be
> recognized.
>
>
>
> Dx Error is also not a ‘Root Cause’.  As in all bad outcomes, a poor
> choice was made at some point along the path(s) to failure.  At that
> decision point, it should be explored as to ‘Why that decision-maker, on
> that day, felt it was the appropriate decision?’.  The answers to this
> question will uncover human reasoning for the decision, which normally was
> made with good intent.  The answers will uncover deficiencies in our
> organizational systems/cultural norms and socio-technical systems that
> influenced the decision-maker.
>
>
>
> As individuals, we tend to judge others based on the outcomes of their
> decisions.  However, we prefer to be judged based on the intent of our own
> decisions.
>
>
>
> If an ‘RCA’ concludes with discipline to an individual for a perceived
> violation of some type, that is basing it on the outcome of their
> decision.
>
>
>
> To me, if we are not exploring the intent of the decision, we are not
> conducting an effective RCA (
> https://reliability.com/pdf/rca-vs-hpi-2017-rci.pdf) and leaving the door
> open to recurrence.
>
>
>
> Obviously a topic near and dear to my heartJ
>
>
>
> Bob
>
>
>
>
>
> *Robert (Bob) J. Latino CEO Reliability Center, Inc.*
> 804-458-0645 (Work)
> 804-452-2119 (Fax)
> blatino at reliability.com
> www.reliability.com
>
> <image001.jpg>
>
> Connect on LinkedIn <http://www.linkedin.com/in/robert-bob-latino-3411097>
>
> <image003.jpg>
>
>
>
> *From:* Rory Jaffe [mailto:rjaffe at chpso.org <rjaffe at chpso.org>]
> *Sent:* Thursday, November 08, 2018 1:36 PM
> *To:* Society to Improve Diagnosis in Medicine <
> IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>; Bob Latino <blatino at reliability.com>
> *Subject:* RE: [IMPROVEDX] ECRI Data
>
>
>
> I doubt it was from the PSO data, as the data fields are not well-suited
> to surveil for diagnostic error. Probably from the expert panel they
> convened, and probably based on zeitgeist rather than hard data.
>
>
>
> Rory Jaffe, MD MBA, Executive Director, CHPSO <http://www.chpso.org/>
>
> 1215 K Street, Suite 930
> Sacramento, CA 95814
> rjaffe at chpso.org
> (916) 552-2600
>
>
>
> <image004.jpg> <http://chpso.org/>
>
>
>
> Subscribe to CHPSO newsletters and announcements
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>
> <image005.jpg> <http://www.hqinstitute.org/hqi2018>
>
>
>
> *From:* Bob Latino <blatino at RELIABILITY.COM>
> *Sent:* Thursday, November 08, 2018 9:24 AM
> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> *Subject:* [No SPF Record] Re: [IMPROVEDX] ECRI Data
>
>
>
> Thanks for posting this Laurie.  This is what they presented at NAHQ.
>
>
>
> What was interesting to me was that Dx Error was not listed at all on the
> past 3 years, and out of the blue it came to the top in 2018.  Does anyone
> know what that is attributable to?  Increased exposure? Better reporting?
>
>
>
> Just curious.
>
>
>
>
>
> *Robert (Bob) J. Latino CEO Reliability Center, Inc.*
> 804-458-0645 (Work)
> 804-452-2119 (Fax)
> blatino at reliability.com
> www.reliability.com
> <https://urldefense.proofpoint.com/v2/url?u=http-3A__www.reliability.com&d=DwMGaQ&c=hx0HUg_nG-xRkKlwWZeJFCbvzzw0Ym5DwdL_1FKbReI&r=ykcs2wU25yxj5BckI49bSg&m=oOijrNtrcT406nRt4K-BmjwEV6cW9pjnxrtFgeBW26A&s=Hx7VfFZG72N3mIBrfNZcSbJV0udp6s20UOwkV2uOniI&e=>
>
> <image001.jpg>
>
> Connect on LinkedIn
> <https://urldefense.proofpoint.com/v2/url?u=http-3A__www.linkedin.com_in_robert-2Dbob-2Dlatino-2D3411097&d=DwMGaQ&c=hx0HUg_nG-xRkKlwWZeJFCbvzzw0Ym5DwdL_1FKbReI&r=ykcs2wU25yxj5BckI49bSg&m=oOijrNtrcT406nRt4K-BmjwEV6cW9pjnxrtFgeBW26A&s=VBJdQiL1HDqciysVyrygbN9FiTHGv1oDavULZEZwGjE&e=>
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> <image003.jpg>
>
>
>
> *From:* Lorie Slass [mailto:Lorie.Slass at IMPROVEDIAGNOSIS.ORG
> <Lorie.Slass at IMPROVEDIAGNOSIS.ORG>]
> *Sent:* Thursday, November 08, 2018 12:06 PM
> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> *Subject:* Re: [IMPROVEDX] ECRI Data
>
>
>
> Here is the ECRI report -
> https://www.ecri.org/EmailResources/PSRQ/Top10/2018_PSTop10_ExecutiveBrief.pdf
> <https://urldefense.proofpoint.com/v2/url?u=https-3A__www.ecri.org_EmailResources_PSRQ_Top10_2018-5FPSTop10-5FExecutiveBrief.pdf&d=DwMGaQ&c=hx0HUg_nG-xRkKlwWZeJFCbvzzw0Ym5DwdL_1FKbReI&r=ykcs2wU25yxj5BckI49bSg&m=oOijrNtrcT406nRt4K-BmjwEV6cW9pjnxrtFgeBW26A&s=elDvkL-8vwpOJvv1G5dFUMepF1Rf80Upzb4f2IOoulo&e=>
>
>
>
>
>
>
>
>
>
> Lorie Slass
> Vice President of Communications and Marketing
> Society to Improve Diagnosis in Medicine (SIDM)
>
> *Lorie.Slass at ImproveDiagnosis.org <Lorie.Slass at ImproveDiagnosis.org> *Phone:
> 215.801.4057
> www.improvediagnosis.org
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> <image006.jpg>
>
>
>
> *From:* Janet Gilbreath <
> 0000001584f7bb70-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG>
> *Sent:* Thursday, November 8, 2018 11:52 AM
> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> *Subject:* Re: [IMPROVEDX] ECRI Data
>
>
>
> I would love to see the top 10 patient safety concerns for 2018.  Would
> you mind putting me in touch with the person who presented this?
>
>
>
> Thanks so much,
>
> Janet Gilbreath
>
> Walmart Care Clinics
>
>
>
> On Thursday, November 8, 2018, 10:40:23 AM CST, Lyn Behnke <
> lynbehnke at GMAIL.COM> wrote:
>
>
>
>
>
> Bob, that would be amazing if I could have access.  I am really interested
> in diagnostic error related to EHR..
>
>
> > On Nov 6, 2018, at 12:45, Bob Latino <blatino at RELIABILITY.COM> wrote:
> >
> > I spoke at the National Association of Healthcare Quality (NAHQ) this
> week, and listened to a presentation by a colleague of mine from ECRI. It
> was entitled ‘The Top 10 Patient Safety Concerns for 2018’.  For the first
> time Dx Error not only made the list, but topped it.
> >
> > I spoke with my friend about their event /incident database which houses
> over 6 million incidents collected via their PSO nationally.  This DB is
> the basis for determining such Top 10 lists.
> >
> > I asked her if SIDM could have access to this knowledge base for
> research purposes and she said they do have such accommodations.  I also
> asked if this list could be data mined to cull out only bad outcomes
> resulting from Dx Error and she said yes.
> >
> > This would be a means of quickly identifying which bad outcomes to focus
> on per Rob Bells suggestion.
> >
> > This is just an FYI as this is a pretty substantial database that is
> maintained very well to keep up the integrity of the data.
> >
> > If this is worth checking out, let me know and I will connect you with
> my contact at ECRI.
> >
> > Bob Latino
> >
> > Sent from my iPhone
> >
> >
> >
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> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
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> To learn more about SIDM visit:
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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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