Errors in diagnosis and a possible way forward.

Bob Latino blatino at RELIABILITY.COM
Wed Nov 28 13:49:14 UTC 2018


In recent posts on this topic, we discussed that PSO’s such as ECRI (and others around the country) have millions of submitted RCA’s based on TJC trigger requirements.  It seems to me, this is the only consistent reservoir of data related to undesirable outcomes.  Of course this is only what is reported, but no use in tackling what is ‘not reported’ at this stage.

Would it make sense to:


1.       Work with PSO’s like ECRI to data mine their RCA knowledge base(s) and sift out bad outcomes where Dx Error was identified as a contributing factor (as it is not THE root cause).

2.       Determine the 80/20 split of these bad outcomes where 20% or less of a certain type of bad outcome (i.e. – Event) accounts for 80% or more of the occurrences.  Degree of severity is usually a factor but in this case, if an RCA ‘had’ to be submitted to TJC, it already met/exceeded a pretty severe trigger.

3.       Of those 20% of the bad outcomes, review the RCA’s for what they determined to be the latent root causes (organizational system flaws and/or the reasoning for the decision errors).  Based on my experience, this is where most RCA’s fall ‘shallow’ and do not delve deep into understanding such reasoning.  However, it is a start to see what evidence was provided for such reasoning that was submitted and reviewed by the PSO RCA experts.

4.       Have a SIDM review committee of some type, take the mined data from the PSO’s Knowledge Base and analyze, under those conditions, what may have been missed by the RCA analysts.

5.       This would provide a working action plan that could be implemented in a pilot environment, where progress could be benchmarked against existing norms.

6.       In the end, if the pilot proved successful, and it was rolled out nationally, results should be able to be measured against the constant, which was the baseline demonstrated in the PSO database.  If successful, there should be a decline in reported bad outcomes of the nature analyzed in the study, due to Dx Error contributions.

Is this everything related to Dx Error absolutely not.  However, it is what is reported, what is known and therefore can be analyzed and benchmarked against.  Lack of proper and effective reporting is a whole other animal that is draped in ambiguity, assumption and lack of sound evidence to work with.

I’m sure there are holes in the above approach, as I am not a clinician or a healthcare professional.  These are just perspectives of an outsider.

Bob

Robert (Bob) J. Latino
CEO
Reliability Center, Inc.
804-458-0645 (Work)
804-452-2119 (Fax)
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From: Jason Maude [mailto:jason.maude at ISABELHEALTHCARE.COM]
Sent: Wednesday, November 28, 2018 5:03 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] Errors in diagnosis and a possible way forward.

Rob
You are still trying to address some almost insurmountable issues like a single payor system.

My view has always been that our missing final link is a measure that regulators can use. They may agree with everything we say and want to include something on diagnosis but need a measure to make it happen. We have spent too long talking about perfect measures and just need 3 (or even one!) that we can agree on and are practical. Hence my long-standing suggestion that the recording of a differential diagnosis in the notes should become a requirement. It makes clinical sense and will be easy to implement and measure if one is present or not.

This small but important measure could start to drive a huge change in behaviour.

An historical example is the abolition of the slave trade in the UK. This was finally achieved via an obscure change in legislation that removed protection for ships flying under the then neutral US flag. It meant that within 2-3 years 80% of the operators in the UK went out of business and then abolition by parliament became easy. The lesson is this seemingly small technical change achieved what 20 years of head on battling had failed to achieve!

Regards
Jason

From: Robert Bell <0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG<mailto:0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG>>
Reply-To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>, Robert Bell <rmsbell200 at YAHOO.COM<mailto:rmsbell200 at YAHOO.COM>>
Date: Tuesday, 27 November 2018 at 23:13
To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>" <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>
Subject: [IMPROVEDX] Errors in diagnosis and a possible way forward.


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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