A couple of questions

Jackson, Brian brian.jackson at ARUPLAB.COM
Mon Dec 3 16:25:25 UTC 2018


I suspect this has more to do with industry structure and current regulatory structure, and less to do with short-term political consequences.  It’s easier to fit sleep requirements into trucking regulation than into medical regulation, because of the way the regulatory process works for trucking and aviation versus medicine (and medical education).

Some of you might have seen this new rule from the U.S. Navy for all sailors to get uninterrupted 8 hour blocks of sleep:  https://www.nytimes.com/aponline/2018/11/23/us/ap-us-navy-sleep-policy.html.  Sounds positive, right?  But now look at how bad things had to get in order to get to this new rule:  https://www.nytimes.com/2017/08/27/world/asia/fatigue-and-training-gaps-spell-disaster-at-sea-sailors-warn.html .  And I thought surgery residents had it bad…

--Brian

From: Peter Loa [mailto:peterloa at GMAIL.COM]
Sent: Sunday, December 02, 2018 1:32 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] A couple of questions

One of the things I struggle with is the high tolerance of patient mistakes and systematic issues by the public and the political system overall.
A plane crash has far more severe political implications than healthcare ever well. MH370 had high level political impact in Malaysia for example.

The cost implications of fatigue management in health will mean that we will never have the same legislative and regulatory structures as aviation and transport have now
 - https://www.icao.int/safety/fatiguemanagement/Pages/FM-Approaches.aspx<https://clicktime.symantec.com/a/1/xxq9F-WWcIRxLQ2X6klRFWRrCd9rKXtw2xIKflB7hms=?d=QFnRV79kUGOSCGBTxFu-lBKVj43_LW94dOOi001V1dH6xXVy0nvNQVPvralJOH-KBn9ycxKZWt5_a9cvY6cN2nKoiRVJhJBOCR6rEoBI5g9RIxfRBJq-8ng82DNGH0h-SpdLjr075txZGxthQpu9o5uxMRfdDvvinr08q8Ak62CdCWEFTO1Ek2PrTZvWBoqT32EpKrep5nj1iHroQUojJJiBAYRKjhuklsrtCPJE7Wvl5wMRI7VBGANKmYPT7F1HHUEI3k7SD6E6zqrzC8_cY3n05BqPRQPsd7p5JocSKOWnBVG3zlwnPwOSN5uqq5IPZRgeh7DkjbDzdt2NnZAKj3Ym6cyTx6aPnhCqwWv-jLo_b5fZbFgkxVnxFW5AKU3wuYlTW1bCBT8jAmfX5lmM_DBSxCOORtLU4xr2CVCxEL5npcoInQ%3D%3D&u=https%3A%2F%2Fwww.icao.int%2Fsafety%2Ffatiguemanagement%2FPages%2FFM-Approaches.aspx>

Peter
Medical Education Registrar
Mackay Base Hospital, Australia

On Mon, 3 Dec 2018 at 03:21, Swerlick, Robert A <rswerli at emory.edu<mailto:rswerli at emory.edu>> wrote:
While aviation is a reasonable industry to model ourselves against, perhaps a better analogy is the transportation industry overall. Healthcare has elements of care delivery where can can aspire to be ultrasafe.

Rene Albermeti and Charles Vincent in their book "Safer Healthcare" (free download and worth reading) delve into these sorts of distinctions.

http://www.bookmetrix.com/detail/book/4227f6d6-099e-4220-9052-b01d3ec6486b#downloads<https://clicktime.symantec.com/a/1/tSyAHBZ0hIDPsgdLk1w3BldR7WpgzDNqpOtfANU0ttY=?d=QFnRV79kUGOSCGBTxFu-lBKVj43_LW94dOOi001V1dH6xXVy0nvNQVPvralJOH-KBn9ycxKZWt5_a9cvY6cN2nKoiRVJhJBOCR6rEoBI5g9RIxfRBJq-8ng82DNGH0h-SpdLjr075txZGxthQpu9o5uxMRfdDvvinr08q8Ak62CdCWEFTO1Ek2PrTZvWBoqT32EpKrep5nj1iHroQUojJJiBAYRKjhuklsrtCPJE7Wvl5wMRI7VBGANKmYPT7F1HHUEI3k7SD6E6zqrzC8_cY3n05BqPRQPsd7p5JocSKOWnBVG3zlwnPwOSN5uqq5IPZRgeh7DkjbDzdt2NnZAKj3Ym6cyTx6aPnhCqwWv-jLo_b5fZbFgkxVnxFW5AKU3wuYlTW1bCBT8jAmfX5lmM_DBSxCOORtLU4xr2CVCxEL5npcoInQ%3D%3D&u=http%3A%2F%2Fwww.bookmetrix.com%2Fdetail%2Fbook%2F4227f6d6-099e-4220-9052-b01d3ec6486b%23downloads>

I would draw your attention to Figure 3.1 on page 29 of the ebook.

Robert A. Swerlick, MD
Alicia Leizman Stonecipher Chair of Dermatology
Professor and Chairman, Department of Dermatology
Emory University School of Medicine
404-727-3669
________________________________
From: Woods, David <woods.2 at OSU.EDU<mailto:woods.2 at OSU.EDU>>
Sent: Saturday, December 1, 2018 8:58 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] A couple of questions

On question 1:

Many such meetings have occurred.  This began first with anesthesia patient safety where international experts from multiple industries got together with APSF in 1990.

The original Annenberg meetings in 1995/1996 that mark the beginning of patient safety as a movement had representatives from multiple industries.  The former Chairman and CEO of Alcoa, Paul H. O’Neil, became heavily involved around 1997, especially focusing on C suite leadership.  Results from many directions defined C suite role in safety (e.g., the CEO leads safety; in cannot be delegated to others;  it must be on the agenda, and first, for board meetings; there should be a subcommittee of the board on safety, ... — and steps like these are minimum floor).

Remember health care is dealing with faulty physiology; aviation does not fly planes with hints of faults (or is not supposed to, e.g., the Lion Air accident is a violation of that and highlights why that is so important in aviation).  This is a major difference among many. Every pilot practices multiple crises every year in recertification training; despite the prevalence of simulation facilities in hospitals, ask how many clinicians have done 1 crisis sim?  then ask how many have done 2? Does any one practice regularly with feedback, reflection, and generalization?  In all of the discussions of improving diagnosis how much does ongoing practice of a systematic set of hard cases figure in? By the way, aviation monitors its crisis training and has become worried that its crisis training programs aren’t effective enough — remember, the goal of practicing realistic difficult situations isn’t simply to be better should that case arise in the real world; they practice hard cases to be better on real cases that are different than ones they have practiced.

Today, aviation has an explicit proactive management approach to safety. While aviation struggles mightily to be proactive, it does not wait for events with harm before taking steps.  It is supposed to monitor early signals through various ongoing efforts and take actions without waiting for bent metal or passenger injuries. Aviation has multiple joint forums between various groups in the industry that worry about and debate early signals and interventions.  Pointedly, aviation does not think of safety as a state, organizational checklist, or result; but rather, there are omnipresent and changing threats to safety and ongoing effort is required to sustain safety. Aviation also backslides: (a)  I was part of the team that reviewed Air France’s safety program after the 447 accident and we had to revise and invigorate the C suite’s role in safety management based on the principles mentioned above; (b) aviation instituted the CRM team training approach that hospitals have tried emulate (in limited ways); a comprehensive aviation industry wide assessment in 2013 found many signs that team work was deteriorating and that team training needed to be reinvigorated and recharged.

Health care does not do much if any of what aviation is focused on in safety today.  Adverse events are wide spread and same ones reoccur and deeper patterns recur; adverse events that are identified usually generate little to no meaningful change.  The institution having adverse events investigates itself; aerospace is built on independent looks at major mishaps. Note the contrast between the independent and public investigation of the Columbia space shuttle accident that focused on it as an organizational failure with widespread changes that are still visible today (I played a minor advisory role and have some connections to more recent near miss events) versus the contemporaneous Jesica Santillan botched double transplant at Duke University Hospital where press reports and lawyer vetted press releases were the only public information.

Yes health care has tried to have dialogues with other industries and sometimes to look more deeply at fundamental patterns in systems safety.  Other industries struggle to sustain safety efforts and to build proactive learning mechanisms.  And yes health care lags well behind the vector of learning and change in systems safety and complex systems safety.  No one industry has the answers.  And threats to safety change dramatically (e.g., ransomware).

I have been told many many times in the last 30 years don’t bring up current difficulties, ongoing struggles, and new directions in systems safety because health care is just trying to catch up to and adopt some basics from where aviation was 10 or 20 years ago (or fill in the blank with whatever industry and whatever time frame).  Meanwhile change continues, complexity grows, systems scale and how to create safety doesn’t stand still.

David




David Woods
Releasing the Adaptive Power of Human Systems

follow @ddwoods2<https://clicktime.symantec.com/a/1/6Nw2ekj0lYOTOMvQ_Hy_GiXg1ynw0jEEEEziwHU56uo=?d=QFnRV79kUGOSCGBTxFu-lBKVj43_LW94dOOi001V1dH6xXVy0nvNQVPvralJOH-KBn9ycxKZWt5_a9cvY6cN2nKoiRVJhJBOCR6rEoBI5g9RIxfRBJq-8ng82DNGH0h-SpdLjr075txZGxthQpu9o5uxMRfdDvvinr08q8Ak62CdCWEFTO1Ek2PrTZvWBoqT32EpKrep5nj1iHroQUojJJiBAYRKjhuklsrtCPJE7Wvl5wMRI7VBGANKmYPT7F1HHUEI3k7SD6E6zqrzC8_cY3n05BqPRQPsd7p5JocSKOWnBVG3zlwnPwOSN5uqq5IPZRgeh7DkjbDzdt2NnZAKj3Ym6cyTx6aPnhCqwWv-jLo_b5fZbFgkxVnxFW5AKU3wuYlTW1bCBT8jAmfX5lmM_DBSxCOORtLU4xr2CVCxEL5npcoInQ%3D%3D&u=https%3A%2F%2Ftwitter.com%2Fddwoods2>

Professor
Department of Integrated Systems Engineering
The Ohio State University

Past-President
Resilience Engineering Association

Past-President
Human Factos and Ergonomic Society

SAVE the DATE
8th Biennial International Symposium on Resilience Engineering
Kalmar Sweden, June 24-27, 2019

woods.2 at osu dot edu
614-946-0123


keynotes on resilience and complexity see
https://www.youtube.com/watch?v=7STcaWjJoww&index=7&list=PL055Epbe6d5YDU6sikjqcd_YM9XT4OehD<https://clicktime.symantec.com/a/1/_Oc_TV9Yd6iPLTgxe9e4XDug_BLo5bVaoz9uipC6-Lo=?d=QFnRV79kUGOSCGBTxFu-lBKVj43_LW94dOOi001V1dH6xXVy0nvNQVPvralJOH-KBn9ycxKZWt5_a9cvY6cN2nKoiRVJhJBOCR6rEoBI5g9RIxfRBJq-8ng82DNGH0h-SpdLjr075txZGxthQpu9o5uxMRfdDvvinr08q8Ak62CdCWEFTO1Ek2PrTZvWBoqT32EpKrep5nj1iHroQUojJJiBAYRKjhuklsrtCPJE7Wvl5wMRI7VBGANKmYPT7F1HHUEI3k7SD6E6zqrzC8_cY3n05BqPRQPsd7p5JocSKOWnBVG3zlwnPwOSN5uqq5IPZRgeh7DkjbDzdt2NnZAKj3Ym6cyTx6aPnhCqwWv-jLo_b5fZbFgkxVnxFW5AKU3wuYlTW1bCBT8jAmfX5lmM_DBSxCOORtLU4xr2CVCxEL5npcoInQ%3D%3D&u=https%3A%2F%2Fwww.youtube.com%2Fwatch%3Fv%3D7STcaWjJoww%26index%3D7%26list%3DPL055Epbe6d5YDU6sikjqcd_YM9XT4OehD>
or
https://www.youtube.com/watch?v=zHJdDMQJXiw&index=8&list=PL7_JAXDeVTvIZ_Y-ddqCiGF-ZKxtM5MLe<https://clicktime.symantec.com/a/1/Yvl_pXFCoGMtr7-Jpaj7Ud4m9ENB5Lha5tZr-h2E9Wo=?d=QFnRV79kUGOSCGBTxFu-lBKVj43_LW94dOOi001V1dH6xXVy0nvNQVPvralJOH-KBn9ycxKZWt5_a9cvY6cN2nKoiRVJhJBOCR6rEoBI5g9RIxfRBJq-8ng82DNGH0h-SpdLjr075txZGxthQpu9o5uxMRfdDvvinr08q8Ak62CdCWEFTO1Ek2PrTZvWBoqT32EpKrep5nj1iHroQUojJJiBAYRKjhuklsrtCPJE7Wvl5wMRI7VBGANKmYPT7F1HHUEI3k7SD6E6zqrzC8_cY3n05BqPRQPsd7p5JocSKOWnBVG3zlwnPwOSN5uqq5IPZRgeh7DkjbDzdt2NnZAKj3Ym6cyTx6aPnhCqwWv-jLo_b5fZbFgkxVnxFW5AKU3wuYlTW1bCBT8jAmfX5lmM_DBSxCOORtLU4xr2CVCxEL5npcoInQ%3D%3D&u=https%3A%2F%2Fwww.youtube.com%2Fwatch%3Fv%3DzHJdDMQJXiw%26index%3D8%26list%3DPL7_JAXDeVTvIZ_Y-ddqCiGF-ZKxtM5MLe>

on the Strategic Agility Gap
https://drive.google.com/open?id=1ISBZPkxxEvEt4mCAiJaarxQ1umwDYUld<https://clicktime.symantec.com/a/1/c7jdvhfmsdgrCAeVSUmc2HkE-xcx7PJFUCXqjh4FYas=?d=QFnRV79kUGOSCGBTxFu-lBKVj43_LW94dOOi001V1dH6xXVy0nvNQVPvralJOH-KBn9ycxKZWt5_a9cvY6cN2nKoiRVJhJBOCR6rEoBI5g9RIxfRBJq-8ng82DNGH0h-SpdLjr075txZGxthQpu9o5uxMRfdDvvinr08q8Ak62CdCWEFTO1Ek2PrTZvWBoqT32EpKrep5nj1iHroQUojJJiBAYRKjhuklsrtCPJE7Wvl5wMRI7VBGANKmYPT7F1HHUEI3k7SD6E6zqrzC8_cY3n05BqPRQPsd7p5JocSKOWnBVG3zlwnPwOSN5uqq5IPZRgeh7DkjbDzdt2NnZAKj3Ym6cyTx6aPnhCqwWv-jLo_b5fZbFgkxVnxFW5AKU3wuYlTW1bCBT8jAmfX5lmM_DBSxCOORtLU4xr2CVCxEL5npcoInQ%3D%3D&u=https%3A%2F%2Fdrive.google.com%2Fopen%3Fid%3D1ISBZPkxxEvEt4mCAiJaarxQ1umwDYUld>








On Nov 30, 2018, at 6:01 PM, ROBERT M BELL <0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG<mailto:0000000296e45ec4-dmarc-request at list.improvediagnosis.org>> wrote:

A couple of questions.

  *   Other industries appear to have better safety records than healthcare - airline, nuclear come to mind. Have meetings between the airline and healthcare industries ever been held to share problems/issues? What were the results? I would have thought that such meetings, even if only preliminary, would have taken place at some time. Have they?
  *   Also, I have always felt that the stethoscope maybe responsible for many errors in diagnosis. One would guess that there would be error differences, assuming good hearing, in say a medical student, intern, resident, fellow, practicing internist and a cardiologist with 30 years of experience. And with hearing loss things may be worse. Does anyone know of any studies that have been undertaken that confirm this hypothesis?
Robert Bell, M.D.



________________________________

Address messages to: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at list.improvediagnosis.org>

To unsubscribe from IMPROVEDX: click the following link:
http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1<https://clicktime.symantec.com/a/1/zFA7DSiJ2gCzyHpDkPKuXLEmqRHisewcpO122fE_9T8=?d=QFnRV79kUGOSCGBTxFu-lBKVj43_LW94dOOi001V1dH6xXVy0nvNQVPvralJOH-KBn9ycxKZWt5_a9cvY6cN2nKoiRVJhJBOCR6rEoBI5g9RIxfRBJq-8ng82DNGH0h-SpdLjr075txZGxthQpu9o5uxMRfdDvvinr08q8Ak62CdCWEFTO1Ek2PrTZvWBoqT32EpKrep5nj1iHroQUojJJiBAYRKjhuklsrtCPJE7Wvl5wMRI7VBGANKmYPT7F1HHUEI3k7SD6E6zqrzC8_cY3n05BqPRQPsd7p5JocSKOWnBVG3zlwnPwOSN5uqq5IPZRgeh7DkjbDzdt2NnZAKj3Ym6cyTx6aPnhCqwWv-jLo_b5fZbFgkxVnxFW5AKU3wuYlTW1bCBT8jAmfX5lmM_DBSxCOORtLU4xr2CVCxEL5npcoInQ%3D%3D&u=http%3A%2F%2Flist.improvediagnosis.org%2Fscripts%2Fwa-IMPDIAG.exe%3FSUBED1%3DIMPROVEDX%26A%3D1>

or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX-SIGNOFF-REQUEST at list.improvediagnosis.org>

Visit the searchable archives or adjust your subscription at: http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX<https://clicktime.symantec.com/a/1/y9xnojGsOP_UUmpVLdfFe1J99_nPtHdcVKyHAoPcHhc=?d=QFnRV79kUGOSCGBTxFu-lBKVj43_LW94dOOi001V1dH6xXVy0nvNQVPvralJOH-KBn9ycxKZWt5_a9cvY6cN2nKoiRVJhJBOCR6rEoBI5g9RIxfRBJq-8ng82DNGH0h-SpdLjr075txZGxthQpu9o5uxMRfdDvvinr08q8Ak62CdCWEFTO1Ek2PrTZvWBoqT32EpKrep5nj1iHroQUojJJiBAYRKjhuklsrtCPJE7Wvl5wMRI7VBGANKmYPT7F1HHUEI3k7SD6E6zqrzC8_cY3n05BqPRQPsd7p5JocSKOWnBVG3zlwnPwOSN5uqq5IPZRgeh7DkjbDzdt2NnZAKj3Ym6cyTx6aPnhCqwWv-jLo_b5fZbFgkxVnxFW5AKU3wuYlTW1bCBT8jAmfX5lmM_DBSxCOORtLU4xr2CVCxEL5npcoInQ%3D%3D&u=http%3A%2F%2Flist.improvediagnosis.org%2Fscripts%2Fwa-IMPDIAG.exe%3FINDEX>


Moderator:David Meyers, Board Member, Society for Improving Diagnosis in Medicine

To learn more about SIDM visit:
http://www.improvediagnosis.org/<https://clicktime.symantec.com/a/1/DDTpVSRIMa77be0Z0KtxExYLXr7NZ2VEppJveD-63XU=?d=QFnRV79kUGOSCGBTxFu-lBKVj43_LW94dOOi001V1dH6xXVy0nvNQVPvralJOH-KBn9ycxKZWt5_a9cvY6cN2nKoiRVJhJBOCR6rEoBI5g9RIxfRBJq-8ng82DNGH0h-SpdLjr075txZGxthQpu9o5uxMRfdDvvinr08q8Ak62CdCWEFTO1Ek2PrTZvWBoqT32EpKrep5nj1iHroQUojJJiBAYRKjhuklsrtCPJE7Wvl5wMRI7VBGANKmYPT7F1HHUEI3k7SD6E6zqrzC8_cY3n05BqPRQPsd7p5JocSKOWnBVG3zlwnPwOSN5uqq5IPZRgeh7DkjbDzdt2NnZAKj3Ym6cyTx6aPnhCqwWv-jLo_b5fZbFgkxVnxFW5AKU3wuYlTW1bCBT8jAmfX5lmM_DBSxCOORtLU4xr2CVCxEL5npcoInQ%3D%3D&u=http%3A%2F%2Fwww.improvediagnosis.org%2F>



________________________________

Address messages to: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>

To unsubscribe from IMPROVEDX: click the following link:
http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1<https://clicktime.symantec.com/a/1/zFA7DSiJ2gCzyHpDkPKuXLEmqRHisewcpO122fE_9T8=?d=QFnRV79kUGOSCGBTxFu-lBKVj43_LW94dOOi001V1dH6xXVy0nvNQVPvralJOH-KBn9ycxKZWt5_a9cvY6cN2nKoiRVJhJBOCR6rEoBI5g9RIxfRBJq-8ng82DNGH0h-SpdLjr075txZGxthQpu9o5uxMRfdDvvinr08q8Ak62CdCWEFTO1Ek2PrTZvWBoqT32EpKrep5nj1iHroQUojJJiBAYRKjhuklsrtCPJE7Wvl5wMRI7VBGANKmYPT7F1HHUEI3k7SD6E6zqrzC8_cY3n05BqPRQPsd7p5JocSKOWnBVG3zlwnPwOSN5uqq5IPZRgeh7DkjbDzdt2NnZAKj3Ym6cyTx6aPnhCqwWv-jLo_b5fZbFgkxVnxFW5AKU3wuYlTW1bCBT8jAmfX5lmM_DBSxCOORtLU4xr2CVCxEL5npcoInQ%3D%3D&u=http%3A%2F%2Flist.improvediagnosis.org%2Fscripts%2Fwa-IMPDIAG.exe%3FSUBED1%3DIMPROVEDX%26A%3D1>
or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG>

Visit the searchable archives or adjust your subscription at: http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX<https://clicktime.symantec.com/a/1/y9xnojGsOP_UUmpVLdfFe1J99_nPtHdcVKyHAoPcHhc=?d=QFnRV79kUGOSCGBTxFu-lBKVj43_LW94dOOi001V1dH6xXVy0nvNQVPvralJOH-KBn9ycxKZWt5_a9cvY6cN2nKoiRVJhJBOCR6rEoBI5g9RIxfRBJq-8ng82DNGH0h-SpdLjr075txZGxthQpu9o5uxMRfdDvvinr08q8Ak62CdCWEFTO1Ek2PrTZvWBoqT32EpKrep5nj1iHroQUojJJiBAYRKjhuklsrtCPJE7Wvl5wMRI7VBGANKmYPT7F1HHUEI3k7SD6E6zqrzC8_cY3n05BqPRQPsd7p5JocSKOWnBVG3zlwnPwOSN5uqq5IPZRgeh7DkjbDzdt2NnZAKj3Ym6cyTx6aPnhCqwWv-jLo_b5fZbFgkxVnxFW5AKU3wuYlTW1bCBT8jAmfX5lmM_DBSxCOORtLU4xr2CVCxEL5npcoInQ%3D%3D&u=http%3A%2F%2Flist.improvediagnosis.org%2Fscripts%2Fwa-IMPDIAG.exe%3FINDEX>

Moderator:David Meyers, Board Member, Society for Improving Diagnosis in Medicine

To learn more about SIDM visit:
http://www.improvediagnosis.org/<https://clicktime.symantec.com/a/1/DDTpVSRIMa77be0Z0KtxExYLXr7NZ2VEppJveD-63XU=?d=QFnRV79kUGOSCGBTxFu-lBKVj43_LW94dOOi001V1dH6xXVy0nvNQVPvralJOH-KBn9ycxKZWt5_a9cvY6cN2nKoiRVJhJBOCR6rEoBI5g9RIxfRBJq-8ng82DNGH0h-SpdLjr075txZGxthQpu9o5uxMRfdDvvinr08q8Ak62CdCWEFTO1Ek2PrTZvWBoqT32EpKrep5nj1iHroQUojJJiBAYRKjhuklsrtCPJE7Wvl5wMRI7VBGANKmYPT7F1HHUEI3k7SD6E6zqrzC8_cY3n05BqPRQPsd7p5JocSKOWnBVG3zlwnPwOSN5uqq5IPZRgeh7DkjbDzdt2NnZAKj3Ym6cyTx6aPnhCqwWv-jLo_b5fZbFgkxVnxFW5AKU3wuYlTW1bCBT8jAmfX5lmM_DBSxCOORtLU4xr2CVCxEL5npcoInQ%3D%3D&u=http%3A%2F%2Fwww.improvediagnosis.org%2F>

________________________________

This e-mail message (including any attachments) is for the sole use of
the intended recipient(s) and may contain confidential and privileged
information. If the reader of this message is not the intended
recipient, you are hereby notified that any dissemination, distribution
or copying of this message (including any attachments) is strictly
prohibited.

If you have received this message in error, please contact
the sender by reply e-mail message and destroy all copies of the
original message (including attachments).

________________________________

Address messages to: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>

To unsubscribe from IMPROVEDX: click the following link:
http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1<https://clicktime.symantec.com/a/1/zFA7DSiJ2gCzyHpDkPKuXLEmqRHisewcpO122fE_9T8=?d=QFnRV79kUGOSCGBTxFu-lBKVj43_LW94dOOi001V1dH6xXVy0nvNQVPvralJOH-KBn9ycxKZWt5_a9cvY6cN2nKoiRVJhJBOCR6rEoBI5g9RIxfRBJq-8ng82DNGH0h-SpdLjr075txZGxthQpu9o5uxMRfdDvvinr08q8Ak62CdCWEFTO1Ek2PrTZvWBoqT32EpKrep5nj1iHroQUojJJiBAYRKjhuklsrtCPJE7Wvl5wMRI7VBGANKmYPT7F1HHUEI3k7SD6E6zqrzC8_cY3n05BqPRQPsd7p5JocSKOWnBVG3zlwnPwOSN5uqq5IPZRgeh7DkjbDzdt2NnZAKj3Ym6cyTx6aPnhCqwWv-jLo_b5fZbFgkxVnxFW5AKU3wuYlTW1bCBT8jAmfX5lmM_DBSxCOORtLU4xr2CVCxEL5npcoInQ%3D%3D&u=http%3A%2F%2Flist.improvediagnosis.org%2Fscripts%2Fwa-IMPDIAG.exe%3FSUBED1%3DIMPROVEDX%26A%3D1> or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG>

Visit the searchable archives or adjust your subscription at: http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX<https://clicktime.symantec.com/a/1/y9xnojGsOP_UUmpVLdfFe1J99_nPtHdcVKyHAoPcHhc=?d=QFnRV79kUGOSCGBTxFu-lBKVj43_LW94dOOi001V1dH6xXVy0nvNQVPvralJOH-KBn9ycxKZWt5_a9cvY6cN2nKoiRVJhJBOCR6rEoBI5g9RIxfRBJq-8ng82DNGH0h-SpdLjr075txZGxthQpu9o5uxMRfdDvvinr08q8Ak62CdCWEFTO1Ek2PrTZvWBoqT32EpKrep5nj1iHroQUojJJiBAYRKjhuklsrtCPJE7Wvl5wMRI7VBGANKmYPT7F1HHUEI3k7SD6E6zqrzC8_cY3n05BqPRQPsd7p5JocSKOWnBVG3zlwnPwOSN5uqq5IPZRgeh7DkjbDzdt2NnZAKj3Ym6cyTx6aPnhCqwWv-jLo_b5fZbFgkxVnxFW5AKU3wuYlTW1bCBT8jAmfX5lmM_DBSxCOORtLU4xr2CVCxEL5npcoInQ%3D%3D&u=http%3A%2F%2Flist.improvediagnosis.org%2Fscripts%2Fwa-IMPDIAG.exe%3FINDEX>
Moderator:David Meyers, Board Member, Society for Improving Diagnosis in Medicine

To learn more about SIDM visit:
http://www.improvediagnosis.org/<https://clicktime.symantec.com/a/1/DDTpVSRIMa77be0Z0KtxExYLXr7NZ2VEppJveD-63XU=?d=QFnRV79kUGOSCGBTxFu-lBKVj43_LW94dOOi001V1dH6xXVy0nvNQVPvralJOH-KBn9ycxKZWt5_a9cvY6cN2nKoiRVJhJBOCR6rEoBI5g9RIxfRBJq-8ng82DNGH0h-SpdLjr075txZGxthQpu9o5uxMRfdDvvinr08q8Ak62CdCWEFTO1Ek2PrTZvWBoqT32EpKrep5nj1iHroQUojJJiBAYRKjhuklsrtCPJE7Wvl5wMRI7VBGANKmYPT7F1HHUEI3k7SD6E6zqrzC8_cY3n05BqPRQPsd7p5JocSKOWnBVG3zlwnPwOSN5uqq5IPZRgeh7DkjbDzdt2NnZAKj3Ym6cyTx6aPnhCqwWv-jLo_b5fZbFgkxVnxFW5AKU3wuYlTW1bCBT8jAmfX5lmM_DBSxCOORtLU4xr2CVCxEL5npcoInQ%3D%3D&u=http%3A%2F%2Fwww.improvediagnosis.org%2F>

________________________________

Address messages to: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>

To unsubscribe from IMPROVEDX: click the following link:
http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1<https://clicktime.symantec.com/a/1/zFA7DSiJ2gCzyHpDkPKuXLEmqRHisewcpO122fE_9T8=?d=QFnRV79kUGOSCGBTxFu-lBKVj43_LW94dOOi001V1dH6xXVy0nvNQVPvralJOH-KBn9ycxKZWt5_a9cvY6cN2nKoiRVJhJBOCR6rEoBI5g9RIxfRBJq-8ng82DNGH0h-SpdLjr075txZGxthQpu9o5uxMRfdDvvinr08q8Ak62CdCWEFTO1Ek2PrTZvWBoqT32EpKrep5nj1iHroQUojJJiBAYRKjhuklsrtCPJE7Wvl5wMRI7VBGANKmYPT7F1HHUEI3k7SD6E6zqrzC8_cY3n05BqPRQPsd7p5JocSKOWnBVG3zlwnPwOSN5uqq5IPZRgeh7DkjbDzdt2NnZAKj3Ym6cyTx6aPnhCqwWv-jLo_b5fZbFgkxVnxFW5AKU3wuYlTW1bCBT8jAmfX5lmM_DBSxCOORtLU4xr2CVCxEL5npcoInQ%3D%3D&u=http%3A%2F%2Flist.improvediagnosis.org%2Fscripts%2Fwa-IMPDIAG.exe%3FSUBED1%3DIMPROVEDX%26A%3D1>
or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG>

Visit the searchable archives or adjust your subscription at: https://clicktime.symantec.com/a/1/y9xnojGsOP_UUmpVLdfFe1J99_nPtHdcVKyHAoPcHhc=?d=QFnRV79kUGOSCGBTxFu-lBKVj43_LW94dOOi001V1dH6xXVy0nvNQVPvralJOH-KBn9ycxKZWt5_a9cvY6cN2nKoiRVJhJBOCR6rEoBI5g9RIxfRBJq-8ng82DNGH0h-SpdLjr075txZGxthQpu9o5uxMRfdDvvinr08q8Ak62CdCWEFTO1Ek2PrTZvWBoqT32EpKrep5nj1iHroQUojJJiBAYRKjhuklsrtCPJE7Wvl5wMRI7VBGANKmYPT7F1HHUEI3k7SD6E6zqrzC8_cY3n05BqPRQPsd7p5JocSKOWnBVG3zlwnPwOSN5uqq5IPZRgeh7DkjbDzdt2NnZAKj3Ym6cyTx6aPnhCqwWv-jLo_b5fZbFgkxVnxFW5AKU3wuYlTW1bCBT8jAmfX5lmM_DBSxCOORtLU4xr2CVCxEL5npcoInQ%3D%3D&u=http%3A%2F%2Flist.improvediagnosis.org%2Fscripts%2Fwa-IMPDIAG.exe%3FINDEX

Moderator:David Meyers, Board Member, Society for Improving Diagnosis in Medicine

To learn more about SIDM visit:
https://clicktime.symantec.com/a/1/DDTpVSRIMa77be0Z0KtxExYLXr7NZ2VEppJveD-63XU=?d=QFnRV79kUGOSCGBTxFu-lBKVj43_LW94dOOi001V1dH6xXVy0nvNQVPvralJOH-KBn9ycxKZWt5_a9cvY6cN2nKoiRVJhJBOCR6rEoBI5g9RIxfRBJq-8ng82DNGH0h-SpdLjr075txZGxthQpu9o5uxMRfdDvvinr08q8Ak62CdCWEFTO1Ek2PrTZvWBoqT32EpKrep5nj1iHroQUojJJiBAYRKjhuklsrtCPJE7Wvl5wMRI7VBGANKmYPT7F1HHUEI3k7SD6E6zqrzC8_cY3n05BqPRQPsd7p5JocSKOWnBVG3zlwnPwOSN5uqq5IPZRgeh7DkjbDzdt2NnZAKj3Ym6cyTx6aPnhCqwWv-jLo_b5fZbFgkxVnxFW5AKU3wuYlTW1bCBT8jAmfX5lmM_DBSxCOORtLU4xr2CVCxEL5npcoInQ%3D%3D&u=http%3A%2F%2Fwww.improvediagnosis.org%2F

 -------------------------------------------------------------------
The information transmitted by this e-mail and any included
attachments are from ARUP Laboratories and are intended only for the
recipient. The information contained in this message is confidential
and may constitute inside or non-public information under
international, federal, or state securities laws, or protected health
information and is intended only for the use of the recipient.
Unauthorized forwarding, printing, copying, distributing, or use of
such information is strictly prohibited and may be unlawful. If you
are not the intended recipient, please promptly delete this e-mail
and notify the sender of the delivery error or you may call ARUP
Laboratories Compliance Hot Line in Salt Lake City, Utah USA at (+1
(800) 522-2787 ext. 2100


To unsubscribe from the IMPROVEDX:
mail to:IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG
or click the following link: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG

Address messages to: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG

For additional information and subscription commands, visit:
http://www.lsoft.com/resources/faq.asp#4A

http://LIST.IMPROVEDIAGNOSIS.ORG/ (with your password)

Visit the searchable archives or adjust your subscription at:
http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX

Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine

To unsubscribe from the IMPROVEDX list, click the following link:<br>
<a href="http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1" target="_blank">http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1</a>
</p>

HTML Version:
URL: <../attachments/20181203/95465e58/attachment.html>


More information about the Test mailing list