CONTACTS 

SUBJECTS
Mistakes Medical Test Reports Doctors Do Not Have Time Read Complex

2003 -
2003 -    ..
2004 - Summary/Objective
2005 -
200501 - Follow up ref SDS 9 DH4O.
200502 -
200503 - Supplement study of medical mistakes to focus on challenges of common
200504 - medical practice to analyse clinical correlationsfor managing complex
200505 - patient history.
200506 -
200507 -
200508 -
200510 -  ..
2006 -
2007 -
2008 - Progress
2009 -
200901 - Limited Time Delays Clinical Correlation Entropy Rises Patient History
200902 -
200903 - Background on 990912 reports the high cost of medical mistakes.
200904 - ref SDS 1 0001  The record on 040416 reviews mistakes and snafus that
200905 - have occurred in Millie's 6 years of treatment. ref SDS 6 GN7J
200907 -  ..
200908 - Reporting on 990912 attributes most mistakes to simple origins in
200909 - poorly designed systems, ref SDS 1 QN8K, that cause communications to
200910 - fail, ref SDS 1 0960, flowing from hectic schedules, fatigue, limited
200911 - span of attention with long hours and high pressure managing complex
200912 - issues of life and death. ref SDS 1 0285
200914 -  ..
200915 - This record today considers difficulty finding enough time for doctors
200916 - to read complex medical test reports.  Limited time forces
200917 - practitioners to glance through impressions of the analyst that
200918 - summarize the gist of findings.  This practice to save time overlooks
200919 - critical trends and notifications in the actual findings, and so
200920 - frustrates requirements to correlate clinically with complex patient
200921 - history in time for effective treatment.
200923 -  ..
200924 - The past 5 years of patient history working with numerous doctors and
200925 - departmental staff at Kaiser indicate that understanding order,
200926 - structure, and patterns in complex patient history degrades with the
200927 - constant increase of new issues.  Since doctors do not have enough
200928 - time for analysis, they cannot add energy required to make clinical
200929 - correlations that maintain connections in complex patient history
200930 - between cause and effect under the locality principle, reviewed on
200931 - 040312. ref SDS 5 YH4G, ref SDS 0 PP8Y, Therefore, the power of
200932 - knowledge to control future results degrades as entropy rises over
200933 - time under the 2nd law of thermodynamics, reviewed on 040312.
200935 -  ..
200936 - Case study of patient history shows...
200937 -
200938 -    1.  PET test on 021218 reports findings
200939 -        of new mild diffuse increased uptakes
200940 -        at region of left supraclavicular,
200941 -        left upper chest, and, also, left axilla;
200942 -        not enough time to align and correlate
200943 -        clinically with increased discomfort
200944 -        under left arm, clincial finding of
200945 -        inflammation on left breast, and
200946 -        patient reports stiff neck fits
200947 -        diagnosis for IBC.................... 030109, ref SDS 2 L66M
200949 -         ..
200950 -    2.  CT scan test on 030626 finds
200951 -        persistant dermal (skin)
200952 -        thickening left breast; notes
200953 -        invasion of dermal lymphatics
200954 -        from known breast cancer can
200955 -        present similarly; left axillary
200956 -        adenopathy nodes measuring 1.5 cm
200957 -        increase 50% from prior study,
200958 -        but not expressly stated;
200959 -        findings attributed to radiation
200960 -        treatment a year earlier; test
200961 -        report recommends correlate
200962 -        clinically; not enough time to
200963 -        separate signal from noise by
200964 -        correlating symptoms reported
200965 -        on 030109 and PET test findings
200966 -        that cite all three elements of
200967 -        IBC diagnosis delayed until
200968 -        040614............................... 030710, ref SDS 3 VM7I
200970 -         ..
200971 -    3.  CT test on 031031 described by
200972 -        doctor as "great" prognosis for
200973 -        patient during progress review
200974 -        meeting at Kaiser.................... 031205, ref SDS 4 LK5L
200976 -         ..
200977 -        2 lymph nodes increased 50% in prior
200978 -        CT test on 030710, not reconciled in
200979 -        follow up test on 031031 without
200980 -        any treatment........................ 031205, ref SDS 4 GJ69
200982 -         ..
200983 -    4.  Patient requests surgeon to perform
200984 -        biopsy investigates growing symptoms
200985 -        of red rash left breast and
200986 -        increasing lymphadenpathy
200987 -        over past year in findings of
200988 -        medical tests........................ 040419, ref SDS 7 789F
200990 -         ..
200991 -    5.  Biopsy diagnoses IBC longevity 18
200992 -        months aligns with symptoms reported
200993 -        in test findings 18 months ago, and
200994 -        continuing recommendations to
200995 -        correlate clinically; not enough
200996 -        time for busy doctor to read
200997 -        findings............................. 040517, ref SDS 8 7D6F
200999 -         ..
201000 -    6.  Lessons learned delay discoverying
201001 -        IBC diagnosis; challenge of limited
201002 -        time prevents doctors from reading
201003 -        complex test findings in time for
201004 -        proactive management................. 040517, ref SDS 8 VG6U
201006 -         ..
201007 -    7.  Esophagitis - doctor did not have time
201008 -        to read findings in PET scan test on
201009 -        060120, and so did not know the test
201010 -        report shows "likely esophagitis,"
201011 -        because this is not mentioned in
201012 -        analysts' summary impression; doctor
201013 -        did not have time to read patient's
201014 -        letter asking about diagnosis and
201015 -        treatment............................. 060428, ref SDS 9 PR9J
201017 -         ..
201018 -    8.  CT test finds new nodes in right
201019 -        paratrcheal region that may support
201020 -        prior findings of esophagitis on PET
201021 -        scan test on 060120; terminology
201022 -        differences prevent practitioners
201023 -        from making mental connections for
201024 -        clinical correlations because
201025 -        doctors do not have enough time to
201026 -        read details buried in long, complex
201027 -        paragraphs; only enough time to read
201028 -        gist of findings in summary impression
201029 -        that does not mention discivering
201030 -        new nodes............................. 060523, ref SDS 10 4O8P
201032 -         ..
201033 -    9.  CT test 060930 doctor not aware of
201034 -        findings enlarged right ventricle
201035 -        heart disorder diagnosed in test
201036 -        findings; Kaiser cannot determine
201037 -        severity comparing right and left
201038 -        ventricle; impact on pulmonary
201039 -        embolism pending review.............., 061020, ref SDS 11 VJ4J
201040 -
201041 -
201042 -
201043 -
201044 -
201045 -
201046 -
2011 -