Kahneman interview - putting a premium on error detection

Seiji Hayashi seiji.hayashi at NPC.HUMANDX.ORG
Thu Feb 7 19:02:51 UTC 2019


Michael, I agree that errors caught a few days later is often fast enough
to avoid harm. This is especially true in primary care. Do you have any
literature or data to support our observations? Please let me know. Thanks!

Seiji
ᐧ

On Thu, Feb 7, 2019 at 1:47 PM Bruno, Michael <
mbruno at pennstatehealth.psu.edu> wrote:

> This is sometimes true – but not as often as you might think, Tom.   We’ve
> found that for the great bulk of reporting errors in practice, if they are
> caught and corrected quickly enough,* i.e., *in a few hours or even a day
> or two, patient harm is truly avoided.
>
>
>
> The embarrassment remains, of course!
>
>
>
> Mike
>
>
>
>
>
> *From:* Tom Benzoni [mailto:benzonit at gmail.com]
> *Sent:* Thursday, February 07, 2019 12:43 PM
> *To:* Society to Improve Diagnosis in Medicine; Bruno, Michael
> *Subject:* Re: [IMPROVEDX] Kahneman interview - putting a premium on
> error detection
>
>
>
> The difficulty here: of the erroneous information was used in the interim,
> the report correction is meaningless.
>
>
>
> I can't unring a bell.
>
>
>
> Tom
>
> On Thu, Feb 7, 2019, 10:53 Bruno, Michael <mbruno at pennstatehealth.psu.edu>
> wrote:
>
> Thanks, Nelson,
>
> Yes, I agree—process changes, but also cognitive changes and an
> accommodation to our basic human biology.  I like to think of errors as
> falling into three categories: (1) those which are due to faults in our
> work processes, (2) t hose which are due to faults in our thinking, and (3)
> those which occur simply because of how we are made.  Each of these will be
> amenable to different solutions—but only error detection after the fact
> addresses all three.
>
> While there are a few diagnoses which, if missed, lead to immediate and
> irreparable harm, most do not.  If we learn to be inclined to expect,
> search for, and rapidly detect errors we will prevent harm MOST of the
> time.  In our experience in radiology, we do on regular occasion detect
> errors which have been present for several hours, such as when a finding is
> missed overnight but picked up on re-review in the morning.  In virtually
> all of these, patient harm was averted by correcting the diagnosis a few
> hours later.
>
> All the best,
>
> Mike
>
>
>
>
>
> *From:* Nelson Toussaint [mailto:ntoussaint at tamarac.com]
> *Sent:* Thursday, February 07, 2019 8:36 AM
> *To:* 'Society to Improve Diagnosis in Medicine'; Bruno, Michael
> *Subject:* Kahneman interview - putting a premium on error detection
>
>
>
>
>
> February 7, 2019
>
> 8:16 AM
>
> *Michael*
>
>
>
> In Aerospace, it is anticipated that this behavior will occur.  Equipment
> will fail and people will make mistakes!  So, a concept of *Accommodation*
> is built into the process to counteract those faults that could lead to
> serious harm.  In some cases you can detect the errors and in some the
> consequences are in play before you can confirm a detection.  So where real
> harm can appear, the Accommodation needs to be somewhat active before/as
> the fault occurs.
>
> An example is the Ground Proximity Warning System, which estimates if the
> airplane may soon fly into terrain (navigation fault of the pilot or
> equipment).  This is only a warning and the pilot must take an action to
> change course.
>
> Early detection of diagnostic error is good; but it still may not be in
> time to limit the potential harm.  A more robust process would include
> methods where the "conclusions" are reviewed before a diagnosis is
> complete.  One that comes to mind is what many of us use quite often -
> "what does this seem like to you"; a discussoin amongst involved parties
> such as the attending physician - radiologist/pathologist – patient.  This
> Accommodation can serve to cause the “experts” to pause and reasses their
> findings.  It does not give a foolproof solution, but still allows the
> experts to continue to form the diagnosis.
>
> This is just a thought, but it seems to me the process changes are the
> best way to attack this problem in order to get broad participation.  The
> trick will be how to modify the process without penalizing the many
> straight-forward cases.
>
>
>
>    Nelson Toussaint
>
>  TAMARAC LLC
>
> 860-844-0199
>
> ntoussaint at tamarac.com
>
>
>
> *From:* Bruno, Michael [mailto:mbruno at PENNSTATEHEALTH.PSU.EDU]
> *Sent:* Tuesday, February 05, 2019 12:41 PM
> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> *Subject:* Re: [IMPROVEDX] Kahneman interview - putting a premium on
> error detection
>
>
>
> Yes,  thanks, Art!
>
> It seems to me that while some errors are preventable, others may well be
> inevitable. The perceptual errors we were talking about at that session at
> DEM are probably biologically rooted (*i.e.,* secondary to neurocognitive
> brain network functions) and are thus essentially outside of our conscious
> control. They are an example of an entire class of errors that flow from
> “how we are made,” our biology and our evolution, and so they will not
> respond to the usual interventions, such as cognitive de-biasing, adult
> learning/CME, or even mindfulness.
>
> So it seems to me that, for these types of errors at least, there needs to
> be a premium placed on *early error detection*, so that errors can be
> more promptly detected and corrected before any patient harm is done.  That
> is the value of double-reading in radiology, and it may be an avenue where
> AI turns out to be particularly helpful in the years ahead.
>
> All the best,
>
>
>
> *Michael A. Bruno, M.D., M.S., F.A.C.R.*
> Professor of Radiology & Medicine
>
> Vice Chair for Quality & Patient Safety
>
> Chief, Division of Emergency Radiology
>
> Penn State Milton S. Hershey Medical Center
> ( (717) 531-8703  |  6 (717) 531-5737
>
> *** mbruno at pennstatehealth.psu.edu  |
>
> *****E-Mail Confidentiality Notice*****
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>
>
>  *From:* Art Papier [mailto:apapier at VISUALDX.COM <apapier at VISUALDX.COM>]
> *Sent:* Sunday, February 03, 2019 2:34 PM
> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> *Subject:* Re: [IMPROVEDX] Kahneman interview
>
>
>
> Thanks for sharing!   Great interview with many fascinating threads, and
> some new thoughts on the randomness of error, and how all error is not due
> to cognitive bias.  Towards the conclusion we hear that Dr. Kahneman in not
> a believer in cognitive debiasing…. saying essentially we are too busy
> making errors to recognize that we are making errors.  He asserts we should
> be thinking about how we recognize other peoples errors.  In made me think
> of the session at DEM on perceptual errors in diagnostic imaging and the
> very positive role of second reads in radiology….whether by humans or AI to
> recognize errors.  Perhaps either co-decision making, or AI “second
> opinions” is an area we should all be further exploring.
>
> Best
>
> Art
>
>
>
> Art Papier MD
>
> CEO VisualDx
>
> Associate Professor of Dermatology and Medical Informatics
>
> University of Rochester College of Medicine
>
>
> ------------------------------
>
>
>
> *From:* Xavier Prida <dr.xavier.prida at GMAIL.COM>
> *Sent:* Sunday, February 03, 2019 8:59 AM
> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> *Subject:* [IMPROVEDX] Kahneman interview
>
>
>
> On "thinking again"- not changing your mind, error, and bias - the latter
> two are not always linked.
>
>
> https://onbeing.org/programs/daniel-kahneman-why-we-contradict-ourselves-and-confound-each-other-jan2019/
> <https://urldefense.proofpoint.com/v2/url?u=https-3A__onbeing.org_programs_daniel-2Dkahneman-2Dwhy-2Dwe-2Dcontradict-2Dourselves-2Dand-2Dconfound-2Deach-2Dother-2Djan2019_&d=DwMGaQ&c=_FmMnDvUH5queZcSmOuBzHZMbp7E7EwtGwv5cxxnTj0&r=XZJky8Jx0OuETXcWpBMhx9j_wSYpSZPDVXdInJ5O9gQ&m=UrbAzwfML-iEIuCykgw2Fqn20pE6WrN96IDUMbiOHMs&s=3X_IjCf1rsQokLp5q2wzaZqF1pXrJky5MKUV2tVppnQ&e=>
>
> XEP
>
>
>
>  *praesent superare odio  **(rise above)*
>
>
>
> Xavier E. Prida MD FACC FSCAI
>
> Assistant Professor of Medicine
>
> Program Director Cardiology Fellowship Training
>
> USF Morsani College of Medicine
>
> Department of Cardiovascular Sciences
>
> 2 Tampa General Circle
>
> STC 5 th Floor
>
> Tampa, Fl 33606
>
> 813 259 0992(O)
>
>
>
>
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Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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