Errors in diagnosis and a possible way forward.

Bob Latino blatino at RELIABILITY.COM
Wed Nov 28 11:16:24 UTC 2018


Forgive me if I tend to repeat myself on this forum, but related to Peter’s message below, I submitted the following as part of a SIDM interview in December/2017. I have been advocating such a discipline approach (both reactive and proactive) to solving complex problems for decades:


1.       Defining Scope of Problem.  I have not been able to understand from SIDM what the definition of a Dx error actually is, therefore I cannot grasp a scope.  It seems SIDM groups all Dx error in one big bucket, as if all of the conditions would be the same or similar.

2.       Quantifying the Problem.  I don’t believe SIDM can be proactive, until they get a handle on the reactive.

a.       Getting a grip on reaction.  I have seen no attempt to break Dx error down into manageable chunks, based on severity of outcomes.  This has been proposed by Dr. Rob Bell and myself for years, to members of the SIDM forum.

                                                               i.      Which type of Dx errors are more commonly resulting in unique types of reportable bad outcomes?

                                                             ii.      What are those reportable bad outcomes (Events)?

                                                            iii.      Can those bad outcomes (in which Dx error contributed) be grouped into Event Categories, and %’s applied to frequency of occurrence and impact/occurrence?

                                                           iv.      Can a listing then be sorted from highest to lowest showing which are the highest impact bad outcomes due to Dx error (Dx is not ‘THE Root Cause’)?

                                                             v.      Normally Pareto would apply and 20% of the types of Bad Outcomes would be occurring 80% of the time (and represent 80% of the adverse impacts).  This would define the population of worst outcomes that should be addressed first, thus breaking overall Dx Error down to manageable chunks.

                                                           vi.      Effective and disciplined RCA could then be applied to Events that are most impactful and would yield the greatest returns in the shortest period of time.

b.      Moving on to proaction.  Once SIDM can control the fix, versus the fix controlling them (reaction), then they can move on to trying to be proactive.

                                                               i.      Proactive means that instead of only quantifying what ‘has’ happened, the focus will shift to what ‘could’ happen.  This is the fundamental premise of Reliability Engineering (Reliability=Proaction=No Surprises).

                                                             ii.      This means that instead of chasing ambulances (reaction), the focus would be on identifying unacceptably high risks, chronic failures (that do not rise to the level of a sentinel event) and near misses.  Their ‘potential’ impacts would be measured based on risk (probability x severity via FMEA type tools).  Effective RCA’s would be applied to such high risks, which is a proactive approach (as we are tackling causes of high risks and not dealing with their consequences).

3.       Dx Error is Not a Commodity.  SIDM has to understand they are unlikely to be successful if they try and tackle all Dx Error as if it is one big problem.

a.       Each Dx Error is a unique occurrence, and conditions under which those decisions were made, are equally unique.  Effective RCA’s will strive to understand the decision-making reasoning that was going on during each occurrence. Inductive reasoning sets in at this stage as influences on the decision-maker are uncovered.

b.      Once such specific latent root causes are identified as actual influencers resulting in bad decisions, they can be grouped into cause categories, which can then be used nationally for tracking and trending purposes.  PSO’s like ECRI have to do such compiling when they filter through the thousands of RCA’s submitted to them, which in turn they have to submit to CMS.  [We have recently discussed the potential use of the ECRI PSO RCA DB for such purposes].
This was just a suggestion on how to get a grip on the overwhelming problem of Dx Error by breaking it down to manageable chunks.  Hopefully a basis in which to work from.

Bob


Robert (Bob) J. Latino
CEO
Reliability Center, Inc.
804-458-0645 (Work)
804-452-2119 (Fax)
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www.reliability.com<http://www.reliability.com>
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From: Elias Peter [mailto:pheski69 at GMAIL.COM]
Sent: Tuesday, November 27, 2018 7:40 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] Errors in diagnosis and a possible way forward.

I agree with Dr. Bell. When faced with what seems like an insurmountable problem, trying BIG solutions requires great cost and effort. And it usually results in BIG failures.

I favor the approach taken by Paul MacCready when he won the Kremer Prize for human-powered flight with his Gossamer Condor.

The discussion of his approach<https://www.fastcompany.com/1663488/wanna-solve-impossible-problems-find-ways-to-fail-quicker> by Aza Raskin is excellent. Here is the crux:

"The problem was the problem. MacCready realized that what needed to be solved was not, in fact, human-powered flight. That was a red herring. The problem was the process itself. And a negative side effect was the blind pursuit of a goal without a deeper understanding of how to tackle deeply difficult challenges. He came up with a new problem that he set out to solve: How can you build a plane that could be rebuilt in hours, not months? And he did. He built a plane with Mylar, aluminum tubing, and wire.”

Instead of trying to solve The Diagnostic Error Problem, we have to find ways to iteratively find and understand error-sets and then design, test, and distribute changed systems.

Peter Elias

On 2018.11.27, at 6:04 PM, Robert Bell <0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG<mailto:0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG>> wrote:


Dear all

I could be wrong but it seems that the problems relating to errors in diagnosis are so massive that any health organization/Society that tries to do something gets mired in the weeds with little eventually happening.

It would seem that that it would be good to tackle one thing at time in a significant way and succeed at something.

Also, the piece by Mike Posata is a good example of the influence of money on errors.

My top three areas for research would be:

  *   Supporting a single payer system, like most of the developed world already has, and investigating the benefits of a single payer system in preventing errors in diagnosis.
That would remove so many hurdles we do not need in medicine. A big challenge but collaboratively, I think, could be done.
  *   Identifying the very commonest errors in diagnosis in each specialty, and working hard on those to prevent them - pulmonary medicine would be my first.
  *   Clarifying all the issues regarding laboratory tests, including, ordering, reporting, interpretation, and subsequent action.
My basic message is to tackle something that is likely to produce results, and can be completed in a defined period of time with the available resources.

Comments very welcome.

Rob Bell, M.D.

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