Welch Company
San Francisco, CA
S U M M A R Y
DIARY: September 12, 1999 09:26 AM Sunday;
Rod Welch
Article in Sunday Times on medical mistakes cause injury and death.
1...Summary/Objective
....................High cost of medical mistakes
........Cost Medical Mistakes $51B Annually Risk Management Cover Up
........Medical Chart Errors Ommissions Speaking Hearing Writing
........Writing Illegible Speaking Hearing Inaccurate Medical Chart
........Risk Management Cover Up Cost Medical Mistakes $51B Annually
..............
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CONTACTS
0201 - Philidelphia Daily News
020101 - Ms. Andrea Gerlin; Reporter
SUBJECTS
High Cost Medical Mistakes Cause Death and Injury 3 Times the Rate o
1403 -
1403 - ..
1404 - Summary/Objective
1405 -
140501 - Follow up ref SDS 33 0000, ref SDS 25 0000.
140502 -
140503 - The front page headline in the Sunday Times today has an article on
140504 - the...
140506 - ..
140507 - High cost of medical mistakes
140508 -
140509 -
140510 - ...cause injuries and death 300% greater than automobile and airline
140511 - accidents combined. ref OF 3 0001 and ref OF 3 0196
140513 - ..
140514 - People are injured and killed by mistakes in hospitals everyday.
140515 - ref OF 4 5820 A major cause of error is miscommunication, reviewed
140516 - further below. ref SDS 0 0960
140517 -
140518 - [On 990924 notified author about cause and solution to mistakes.
140519 - ref SDS 42 0001]
140521 - ..
140522 - [On 990924 major cause of medical mistakes is rising
140523 - complexity of modern health care that overwhelms span of
140524 - attention, and so degrades communication; requires a new role to
140525 - assist doctors and patients with case management. ref SDS 42
140526 - 2955
140528 - ..
140529 - [On 991001 "little mistake" crashes NASA space craft on Mars.
140530 - ref SDS 43 0001]
140532 - ..
140533 - [On 991028 Robert Pearl, CEO at Kaiser, submitted letter to
140534 - membership announcing efforts to improve quality team care.
140535 - ref SDS 47 0800]
140537 - ..
140538 - [On 991207 President Clinton announces national initiative to
140539 - reduce medical mistakes. ref SDS 50 0889
140541 - ..
140542 - [On 991221 study finds that doctors do not communicate
140543 - adequately with patients 90% of the time. ref SDS 52 0001
140545 - ..
140546 - [On 040416 case study medical mistakes Millie's patient history.
140547 - ref SDS 58 GN7J
140549 - ..
140550 - [On 040419 examples of simple mistakes that occur inadvertently,
140551 - ref SDS 59 XU83, due to limited time, complexity, and in some
140552 - cases routine, repetitive tasks, where span of attention wanders
140553 - slightly. ref SDS 59 HH5G
140555 - ..
140556 - [On 041012 medical management exasperating because staff fail to
140557 - invest time for organizing the record, causing mistakes, delay
140558 - and cost escalation. ref SDS 60 NV49
140560 - ..
140561 - [On 041018 UCSF Cancer Center verifies CA 15-3 cancer marker
140562 - dropped to normal by checking the documentation; says cancer
140563 - marker not important to patient evaulation. ref SDS 62 L16Q
140565 - ..
140566 - [On 041019 Stanford Cancer Center checks the record of
140567 - documentation to verify accuracy of patient history. ref SDS 63
140568 - OW88
140570 - ..
140571 - [On 041125 AHRQ publication confirms high cost of medical
140572 - mistakes caused by communication errors offers 20 tips to save
140573 - time and money by preventing errors and omissions in health
140574 - care. ref SDS 64 SD6N
140576 - ..
140577 - [On 050409 Lilly's sister contracted an infection during a stay
140578 - at the hospital, and was treated with an outpatient IV.
140579 - ref SDS 67 6R5J
140581 - ..
140582 - [On 050824 Advice Nurse persistant reminds surgeon to implement
140583 - requirements in Kaiser's Healthwise Handbook following up
140584 - patient calls to collaborate and coordinate via email on
140585 - accuracy of communication and patient medical history.
140586 - ref SDS 69 4M7N
140588 - ..
140589 - [On 051103 study shows 34% of patients report experiencing
140590 - medical mistakes. ref SDS 70 ET68
140592 - ..
140593 - [On 060615 example quality care issues facing hospitals.
140594 - ref SDS 72 TB6R
140596 - ..
140597 - [On 060808 small, inconsequential mistake in medical chart
140598 - shows patient being treated with Coumadin for pulmonary emboli,
140599 - which was actually stopped 10 months earlier; backup doctor
140600 - does not know medical chart is incorrect; primary care
140601 - physician on vacation when notice received of genetic cause for
140602 - pulmonary emboli in patient's family, and so assumes that since
140603 - patient is already receiving treatment, no action is required.
140604 - ref SDS 73 A45F
140606 - ..
140607 - [On 060809 Margaret at UCSF, Sherry's colleague, also, has
140608 - hectic schedule, not enough time to communicate with patient,
140609 - ref SDS 74 YK6N, nor to organize the record for the doctor to
140610 - make a timely review and conduct an effective meeting.
140611 - ref SDS 74 I73H
140613 - ..
140614 - [On 080911 article Why Doctors Make Mistakes explains problems
140615 - of busy doctors overwhelmed by hectic schedule rely on personal
140616 - memory and conversation, do not have time for analysis to review
140617 - patient history. ref SDS 82 U17Q
140619 - ..
140620 - Follow up articles on 990913, 990914, and 990915, reported...
140621 -
140622 - 1. Many mistakes have... simple origins in poorly designed
140623 - systems... ref OF 4 1406
140624 -
140625 - New World Order... cites Aristotole's rule that little
140626 - deviations grow over time into big mistakes. ref OF 8 6056
140627 - Morris commented on executives ignoring small, innocuous
140628 - conflicts with objectives, requirements, and commitments that
140629 - seem like unnecesary overkill to fix at the time, because
140630 - everybody is busy working on big problems, but later the small
140631 - problems explode into major crisis and calamity. ref SDS 2
140632 - 0674
140634 - ..
140635 - On 990625 Kaiser has good procedures, but doctors don't have
140636 - time to use them, ref SDS 24 2652, and prefer to work
140637 - spontaneously by conversation, because it is fast and easy.
140638 - ref SDS 24 1978
140639 -
140640 - [On 990910 multiple mistakes on visit to Kaiser. ref SDS 40
140641 - 3038]
140643 - ..
140644 - [On 991008 requested meeting to review team care practices to
140645 - support doctor/patient partnership. ref SDS 46 5727]
140647 - ..
140648 - [On 991028 Kaiser's doctors have freedom to practice medicine
140649 - as it should be practiced, but no guidelines established.
140650 - ref SDS 47 2555]
140652 - ..
140653 - [On 000122 Kaiser addresses medical mistakes. ref SDS 53 0863
140655 - ..
140656 - [On 000207 doctors are pressed for time because meetings with
140657 - patients are scheduled every 15 minutes. ref SDS 54 0788
140659 - ..
140660 - [On 000211 Dale Ames experiences comedy of errors in medical
140661 - practice. ref SDS 55 3600]
140663 - ..
140664 - [On 040419 simple communication mistakes occur inadvertently,
140665 - ref SDS 59 XU83, due to limited time, complexity, and in some
140666 - cases routine, repetitive tasks, where span of attention
140667 - wanders slightly. ref SDS 59 HH5G
140669 - ..
140670 - [On 041012 medical management exasperating because staff fail
140671 - to invest time for organizing the record, causing mistakes,
140672 - delay and cost escalation. ref SDS 60 NV49
140674 - ..
140675 - [On 060428 doctors limited time prevents reading findings to
140676 - correlate clinically that discovers trends for proactive
140677 - management; there is only enough time to read summaries on
140678 - the gist of findings. ref SDS 71 VG5L
140680 - ..
140681 - 2. Communication errors are the biggest cause for the high cost of
140682 - medical mistakes, per above. ref SDS 0 0001 Major cause of
140683 - mistakes in health care occurs from errors in the medical
140684 - chart, ref SDS 0 4T4H, many due to illegible writing, further
140685 - noted below. ref SDS 0 0900
140686 -
140687 - [On 990924 major cause of medical mistakes care is rising
140688 - complexity of modern health care that overwhelms span of
140689 - attention, and so degrades communication; requires a new
140690 - role to assist doctors and patients with case management.
140691 - ref SDS 42 2955
140693 - ..
140694 - [On 041125 AHRQ publication confirms high cost of medical
140695 - mistakes caused by communication errors offers 20 tips to
140696 - reduce. ref SDS 64 SD6N
140698 - ..
140699 - [On 080318 people typically manage health care records with
140700 - a shirt-pocket binder containing quickly scralled notes of
140701 - cursory understandings. ref SDS 80 GZ4X
140703 - ..
140704 - [On 080911 article Why Doctors Make Mistakes explains
140705 - problems of busy doctors overwhelmed by hectic schedule
140706 - rely on personal memory and conversation, do not have time
140707 - for analysis to review patient history. ref SDS 82 U17Q
140709 - ..
140710 - Executives everywhere work by conversation, reported on 911123.
140711 - ref SDS 1 3739
140713 - ..
140714 - Kaiser publishes a Healthwise Handbook with well recognized
140715 - procedures to make communication effective by writing things
140716 - down...
140717 -
140718 - a. Accurate communication yields good
140719 - diagnosis, planning, treatments,
140720 - monitoring, and
140721 - results........................... 990625, ref SDS 24 3190
140723 - ..
140724 - b. Written record best evidence
140725 - of accurate listening
140726 - essential for effective
140727 - communication..................... 990625, ref SDS 24 JY9J
140729 - ..
140730 - c. Written record in Medical Chart
140731 - review by patient documents accurate
140732 - communication for timely,
140733 - comprehensive
140734 - care.............................. 990625, ref SDS 24 TD5S
140736 - ..
140737 - d. Written records improve accuracy
140738 - of human memory by orders of
140739 - magnitude to avoid medical
140740 - mistakes.......................... 990625, ref SDS 24 GT62
140742 - ..
140743 - e. Submit written agenda to be prepared
140744 - for productive meetings with patient
140745 - history of symptoms and response to
140746 - treatments......................... 990625, ref SDS 24 5740
140748 - ..
140749 - f. Sharing written communications
140750 - builds better doctor patient partnership
140751 - through shared memory that avoids
140752 - mistakes........................... 990625, ref SDS 24 TD6Q
140754 - ..
140755 - g. Ping pong follow up provides feedback
140756 - loops that verify accuracy to avoid
140757 - the high cost of medical
140758 - mistakes........................... 990625, ref SDS 24 3960
140760 - ..
140761 - Poor communication due to limited time is the highest risk in
140762 - enterprise, reviewed on 951212. ref SDS 5 4433 On 990625
140763 - Doctor Sylvia Connolly reported doctors do not have enough time
140764 - to perform Kaiser requirements to verify accurate
140765 - communication, so patients can help fill the gap. ref SDS 24
140766 - 1978
140768 - ..
140769 - Hectic schedules make people pressed for time; writing things
140770 - down seems like unnecessary overkill. Therefore, feedback to
140771 - verify accuracy is essential because mere silence may mean
140772 - information was lost, misdirected, misunderstood, forgotten,
140773 - ignored, applied incorrectly, personnel changed who feel
140774 - uncomfortable requesting assistance to solve complex problems,
140775 - people fear accountability and seek safety through deniability
140776 - by avoiding written records, etc. There are many reasons
140777 - feedback might not occur other than that concurrence makes
140778 - response seem unnecessary.
140780 - ..
140781 - [On 990924 developed analysis that communication is biggest
140782 - risk in communication. ref SDS 42 5576]
140784 - ..
140785 - [On 991216 Tom Driscoll at Kaiser feels analysis on 990924
140786 - citing reports that communication is major risk, is only
140787 - opinion. ref SDS 51 3808
140789 - ..
140790 - [On 991221 study finds that doctors do not communicate
140791 - adequately with patients 90% of the time. ref SDS 52 0001
140793 - ..
140794 - [On 000207 doctors are pressed for time because meetings with
140795 - patients are scheduled every 15 minutes, so there is not
140796 - enough time to verify accuacy of communication. ref SDS 54
140797 - 0788
140799 - ..
140800 - [On 010514 miscommunication on major surgery. ref SDS 56 U882
140802 - ..
140803 - [On 041019 Stanford Cancer Center checks the record to verify
140804 - accuracy of patient history. ref SDS 63 OW88
140806 - ..
140807 - [On 050311 doctors have difficulty with communication and
140808 - collaboration among themselves preparing timely reports,
140809 - distribution, review, and feedback. ref SDS 66 PB8N
140811 - ..
140812 - [On 050824 Advice Nurse being persistant reminding the
140813 - surgeon to implement requirements in Kaiser's Healthwise
140814 - Handbook following up patient calls to collaborate and
140815 - coordinate via email on accuracy of communication and patient
140816 - medical history. ref SDS 69 4M7N
140818 - ..
140819 - [On 051103 study shows 34% of patients report experiencing
140820 - medical mistakes due to communication gap. ref SDS 70 ET68
140822 - ..
140823 - [On 060428 doctors limited time prevents reading findings to
140824 - correlate clinically that discovers trends for proactive
140825 - management; there is only enough time to read summaries on
140826 - the gist of findings. ref SDS 71 VG5L
140828 - ..
140829 - [On 080911 article Why Doctors Make Mistakes explains
140830 - problems of busy doctors overwhelmed by hectic schedule rely
140831 - on personal memory and conversation, do not have time for
140832 - analysis to review patient history. ref SDS 82 U17Q
140834 - ..
140835 - Medical communication is comparable in complexity to aviation,
140836 - which has reduced the rate of errors significantly, while
140837 - medical mistakes remain unchanged. ref OF 6 2312
140838 -
140839 - [On 990924 medical practice makes less mistakes than other
140840 - professions, ref DIP 2 0001, but communication biggest risk
140841 - of error in all professions, ref DIP 3 0001, developed on
140842 - 991028. ref SDS 48 0001]
140844 - ..
140845 - [On 040419 simple communication mistakes occur inadvertently,
140846 - ref SDS 59 XU83, due to limited time, complexity, and in some
140847 - cases routine, repetitive tasks, where span of attention
140848 - wanders slightly. ref SDS 59 HH5G
140850 - ..
140851 - Deming is cited as comparing medical care with aviation.
140852 - ref OF 4 1247
140853 -
140854 - Aviation uses "feedback" to verify communication with the
140855 - tower when flying a plane, as reported on 971229.
140856 - ref SDS 13 2914 Communication Metrics applies feedback to
140857 - add "intelligence" to management. ref OF 7 0582 Pilots
140858 - don't use feedback on the ground, and neither do mechanics
140859 - to maintain the plane, nor executives to manage the pilots
140860 - and other elements in avaiation, because executives,
140861 - pilots, doctors, nobody likes feedback. ref SDS 13 3778
140863 - ..
140864 - Aviation has economies of scale that are missing from
140865 - medical practice. A bunch of experts can afford to work
140866 - carefully on an airplane, because that one plane flys a lot
140867 - of people for a long time whose ticket price generates
140868 - revenue to pay for shoes, housing, TV, food and other stuff
140869 - for the maintenance crew. The lead mechanic carefully
140870 - reviewes the plane log and reports by pilots on inflight
140871 - problems. Airplane history is reviewed to see what was
140872 - fixed previously and frequency of failure for clues about
140873 - where to focus attention during service.
140875 - ..
140876 - The inverse is the case if the plane crashes, and survivors
140877 - receive medical treatment. Then a bunch of people work on
140878 - a single person, whose chances of living are already pretty
140879 - slim; then they have work on another person, and another,
140880 - i.e., doctors typically have a lot of patients under their
140881 - care, rather than a lot of mechanics working on one plane.
140882 - The cost per person skyrockets, so attention per person
140883 - goes down relative to a big airplane. Medical history is
140884 - not available, and if it is there isn't time for review.
140885 - Doctors have to pull off the project and let the body heal
140886 - itself, then later try more treatment ideas. Aviation
140887 - mechanics stay on the job until everything is fixed and
140888 - tested. Medical economics disperse expertise, rather than
140889 - focus it, as in aviation. There are billions of people and
140890 - only a million or so airplanes. Nominally medicine is
140891 - harder to learn than airplane mechanics because the plans
140892 - and specs for the human body, and replacement parts are not
140893 - as readily available as in aviation. Economies of scale,
140894 - lack of knowledge and spare parts make medical practice
140895 - more difficult and higher risk than in aviation.
140897 - ..
140898 - Car service is a better analogy to medical treatment, and both
140899 - make about the same number of mistakes, as reported on 990507.
140900 - ref SDS 21 0001
140901 -
140902 - ...patient care is fragmented work due to staff changes during
140903 - shifts, and people being added and leaving the treatment team.
140904 - ref OF 4 1406
140905 -
140906 -
140907 -
140908 -
1410 -
SUBJECTS
Writing Illegible People Die from Poor Penmenship Spelling Communcia
1903 -
190401 - ..
190402 - Cost Medical Mistakes $51B Annually Risk Management Cover Up
190403 - Medical Chart Errors Ommissions Speaking Hearing Writing
190404 - Writing Illegible Speaking Hearing Inaccurate Medical Chart
190405 -
190406 - 3. High cost of medical mistakes is $51B per year, ref OF 6 1184,
190407 - largely due to common communication failures. ref OF 3 4897
190408 -
190409 - [On 991207 federal study found medical mistakes cost $29B.
190410 - ref SDS 50 5824
190412 - ..
190413 - On 990625 Kaiser's Healthwise Handbook calls for doctor/patient
190414 - partnership to strengthen communication. ref SDS 24 4185
190415 - Listening makes communication more effective, ref SDS 24 4752,
190416 - aided by writing a timely record of examinations showing
190417 - symptoms, diagnosis and treatment in the medical chart,
190418 - ref SDS 24 5740, and using a "ping pong" method of feedback
190419 - with the patient to refine accuracy. ref SDS 24 3960
190421 - ..
190422 - Published guidance on 990625 explains accuracy of medical chart
190423 - is foundation of health care. ref SDS 24 PX6H and ref SDS 24
190424 - GT62
190426 - ..
190427 - Doctors report there isn't enough time to comply with
190428 - requirements for accurate communications. ref SDS 24 1978
190429 -
190430 - [On 020504 study shows professional standards for
190431 - communication practices and requirements on good management
190432 - specified in FAR, ISO, Health Care, Covey, Drucker, law,
190433 - contract notice provisions, and 2,000 years of literacy for
190434 - contemporaneous documentation for alignment and feedback to
190435 - work intelligently, quickly, and accurately are ignored in
190436 - government, business, health care, every sector.
190437 - ref SDS 57 NS6F
190439 - ..
190440 - [On 050520 Kaiser introduces computers for electronic
190441 - medical chart that improves ligibility to reduce mistakes
190442 - treating patients. ref SDS 68 HX6J
190444 - ..
190445 - [On 061208 mistakes in electronic medical chart stored on
190446 - the computer cannot be corrected because Kaiser "locks
190447 - down" the record after the doctor meets with the patient;
190448 - prevents feedback loops called out in Healthwise Handbook
190449 - from correcting the medical chart. ref SDS 76 N54K
190451 - ..
190452 - [On 080911 article Why Doctors Make Mistakes explains
190453 - problems of busy doctors overwhelmed by hectic schedule
190454 - rely on personal memory and conversation, do not have time
190455 - for analysis to review patient history. ref SDS 82 U17Q
190457 - ..
190458 - Importance of investing time for accuracy is increased by
190459 - complexity of medical practice. Different medications come in
190460 - similar packages, have similar names. Misspelling,
190461 - mis-speaking, mis-hearing cause errors. ref OF 4 2754
190462 -
190463 - One doctor wrote with exasperation in the medical chart....
190464 -
190465 - DO NOT KILL MR CROOKS
190467 - ..
190468 - Medical residents then mistakenly gave the patient insulin,
190469 - which caused a seizure, a hypoglycemic shock. ref OF 4 2940
190471 - ..
190472 - Handwritting is illegible ...people die of penmanship errors.
190473 - ref OF 4 6240
190474 -
190475 - [On 991224 telephone game that exemplifies meaning drift,
190476 - developed to respond to author. ref SDS 42 3955]
190477 -
190478 - [On 991006 handwritting illegible in vehicle service
190479 - records. ref SDS 44 2055]
190481 - ..
190482 - [On 000207 doctors are pressed for time because meetings
190483 - with patients are scheduled every 15 minutes, so there is
190484 - not enough time to verify accuracy of communication, nor to
190485 - write clear, concise, complete records for the medical
190486 - chart, including prescriptions. ref SDS 54 0788
190488 - ..
190489 - [On 040419 example hurried tired staff increases risk of
190490 - communication mistakes in medical practice. ref SDS 59 HH5G
190492 - ..
190493 - [On 041014 doctor notes in the medical chart on patient
190494 - examinations are illegible. ref SDS 61 W78K
190496 - ..
190497 - [On 041018 Doctor Benz at UCSF Cancer Center reports that
190498 - handwritten notes on examinations filed in the patient's
190499 - medical chart are often not readable and so are not reviewed
190500 - to prepare a patient history for rendering a 2nd opinion.
190501 - ref SDS 62 EN63
190503 - ..
190504 - [On 041130 written work plan submitted by doctor illigible,
190505 - conflicts with Breast Cancer Treatment Guidelines for
190506 - Patients on page 52. ref SDS 65 9V71
190508 - ..
190509 - [On 060821 Doctor Benz at UCSF relies on Kaiser's medical
190510 - chart created with computer that produces legible doctor
190511 - Progress Notes. ref SDS 75 TQ5I
190513 - ..
190514 - [On 060821 Doctor Benz at UCSF relied on Kaiser's medical
190515 - chart because the record produced on a computer is legible;
190516 - since the medical chart incorrectly shows the patient being
190517 - treated with warfarin (Coumadin) for pulmonary embolism, the
190518 - doctor does not comply with patient's request for UCSF to
190519 - investigate symptoms of pulmoanry embolism which at that time
190520 - were not be being treated at Kaiser. ref SDS 75 PM4N
190522 - ..
190523 - [On 061208 Kaiser "locks down" medical chart preventing
190524 - doctor from correcting mistakes in progress notes on patient
190525 - history, eliminating benefits of feedback loops from doctor
190526 - patient partnerhsip to reduce medical mistakes. ref SDS 76
190527 - 025H
190529 - ..
190530 - [On 080306 example hurried handwriting that is illegible
190531 - prescribing medication. ref SDS 79 NW5O
190533 - ..
190534 - [On 080403 example hurried handwriting that is illegible
190535 - ordering Neupogen treatment. ref SDS 81 I35G
190536 -
190537 -
190538 -
190539 -
190540 -
1906 -
SUBJECTS
Default Null Subject Account for Blank Record
2003 -
200401 - ..
200402 - Risk Management Cover Up Cost Medical Mistakes $51B Annually
200403 -
200405 - ..
200406 - 4. Risk Managers are contacted after mistakes occur to limit
200407 - liability, rather than develop procedures and training to limit
200408 - mistakes. ref OF 5 3520
200410 - ..
200411 - On 951212 risk management requires processes to reduce risks so
200412 - mistakes are avoided. ref SDS 5 4433
200413 -
200414 - [On 991001 Lockheed and NASA perform risk management
200415 - investigation to align communications after mistakes are
200416 - made. ref SDS 43 0304]
200417 -
200419 - ..
200420 - 5. Pressures from long hours, being tired, hungry, bored, anxious,
200421 - frightened, and under scrutiny by superiors, all increase
200422 - mistakes. ref OF 4 4514
200423 -
200424 - [On 991006 example at Kaiser. ref SDS 45 3596]
200425 -
200426 - [On 000207 doctors are pressed for time because meetings
200427 - with patients are scheduled every 15 minutes, so there is
200428 - not enough time to verify accuate communication. ref SDS 54
200429 - 0788
200431 - ..
200432 - [On 041012 medical management exasperating because staff
200433 - fail to invest time for organizing the record, causing
200434 - mistakes, delay and cost escalation. ref SDS 60 NV49
200436 - ..
200437 - 6. Hurrying causes mistakes, not enough time to succeed.
200438 - ref OF 4 4514
200440 - ..
200441 - This is a dimension of information density that overwhelms
200442 - limited span of attention; curiously information overload is
200443 - not mentioned, however, in the articles.
200444 -
200445 - [On 990924 cite information overload as cause of mistakes.
200446 - ref SDS 42 3955]
200448 - ..
200449 - [On 040419 medical mistakes flow from simple communication
200450 - deviations from objectives, requirements, and commitments
200451 - which go unnoticed and uncorrected, ref SDS 59 XU83, due to
200452 - limited time, complexity, and in some cases routine,
200453 - repetitive tasks, where span of attention wanders slightly.
200454 - ref SDS 59 HH5G
200456 - ..
200457 - [On 040419 example hurried, tired staff increases risk of
200458 - communication mistakes in medical practice. ref SDS 59 HH5G
200460 - ..
200461 - [On 060428 doctors limited time prevents reading medical
200462 - test findings to correlate clinically that discovers
200463 - symptomatic trends for proactive management; there is only
200464 - enough time to read summaries on the gist of findings.
200465 - ref SDS 71 VG5L
200467 - ..
200468 - Not having enough time to perform communication tasks,
200469 - including review medical history, is not mentioned in the
200470 - article, but was reported at Kaiser on 990625. ref SDS 24 0889
200471 -
200472 - [On 000207 doctors are pressed for time because meetings
200473 - with patients are scheduled every 15 minutes, so there is
200474 - not enough time to verify accuate communication. ref SDS 54
200475 - 0788
200477 - ..
200478 - [On 070119 Kaiser did not have enough time to verify the
200479 - complete blood test report was submitted to UCSF required to
200480 - begin treatment for cancer on clinical study. ref SDS 77
200481 - M56N
200483 - ..
200484 - [On 070330 hectic schedule, fatigue, not enough time check
200485 - record doctor prescribes treatment should defer to referral
200486 - team for control of clinical study. ref SDS 78 S76N
200488 - ..
200489 - [On 080911 article Why Doctors Make Mistakes explains
200490 - problems of busy doctors overwhelmed by hectic schedule rely
200491 - on personal memory and conversation, do not have time for
200492 - analysis to review patient history. ref SDS 82 U17Q
200494 - ..
200495 - 7. Culture of denial is biggest cause of errors...
200496 -
200497 - The American Medical Association's Council on Ethical and
200498 - Judicial Affairs requires doctors to disclose errors to
200499 - patients; but, this is routinely not followed, because doctors
200500 - feel their competence is challenged, ref OF 5 9388, which
200501 - puts at risk their livilhood.
200502 -
200503 - [On 990924 letter explains worry that steps to improve the
200504 - work causes challenges about competence. ref SDS 42 3966]
200506 - ..
200507 - [On 991101 personal competence of doctors prevents improving
200508 - medical practice. ref SDS 49 2562
200510 - ..
200511 - Denial is cited in a follow up article published on 990915.
200512 - ref OF 4 1862
200513 -
200514 - On 971017 engineers feel their competence is challenged by
200515 - using Communication Metrics to improve management.
200516 - ref SDS 9 4814
200518 - ..
200519 - On 980307 Andy Grove, CEO of Intel, says in his book that
200520 - inertia of success causes denial that prevents improvement.
200521 - ref SDS 14 3740 and ref SDS 14 2044
200523 - ..
200524 - On 980405 accountability fosters culture of denial that
200525 - slows improving management. ref SDS 17 5065
200527 - ..
200528 - On 990505 "attitude" needs to change before improving
200529 - communication. ref SDS 20 4732
200531 - ..
200532 - On 990527 strong cultural forces prevent better management.
200533 - ref SDS 22 1233
200534 -
200535 - [On 990924 letter explains "culture" and "attitude"
200536 - solved by leadership. ref SDS 42 3966]
200537 -
200538 - [On 020504 study shows professional standards for
200539 - communication practices and requirements on good
200540 - management specified in FAR, ISO, Health Care, Covey,
200541 - Drucker, law, contract notice provisions, and 2,000 years
200542 - of literacy for contemporaneous documentation for
200543 - alignment and feedback to work intelligently, quickly,
200544 - and accurately are ignored in government, business,
200545 - health care, every sector. ref SDS 57 NS6F
200547 - ..
200548 - Medical mistakes can be reduced by changing the culture.
200549 - ref OF 4 4088
200551 - ..
200552 - Feedback is discouraged by fear of retribution, ref OF 4 1862,
200553 - reflecting analysis in NWO... paper. ref OF 8 2670
200555 - ..
200556 - Asking for help is discouraged.
200558 - ..
200559 - Challenging supervisors, a form of "feedback," is discouraged
200560 - by fear of retribution.
200562 - ..
200563 - Accountability discourages accurate communication about lack of
200564 - alignment, commonly called mistakes, ref OF 6 5162, reflecting
200565 - review on 980405. ref SDS 17 5065
200566 -
200567 - On 971202 accountability is "stressed" in the U.S. Army
200568 - Corps of Engineers policy. ref SDS 12 7453
200570 - ..
200571 - On 980403 U.S. Army Corps of Engineers executive disclosed
200572 - that managers actually fear accountability. ref SDS 16 6581
200574 - ..
200575 - Most mistakes are due to oversight and negligence, rather than
200576 - incompetence. ref OF 6 0859
200578 - ..
200579 - More mistakes, however, occur in law, engineering, energy, insurance,
200580 - journalism, agriculture, government, education, indeed, every sector
200581 - of the business community suffers from information overload that
200582 - overwhelms human span of attention, reported on 970829, ref SDS 7
200583 - 4181, which causes small deviations from requirements that go
200584 - unnoticed, due to lack of feedback loops, until mistake occurs, as
200585 - explained in the NWO... paper. ref OF 8 6056
200586 -
200587 - [On 051103 study shows 34% of patients report experiencing
200588 - medical mistakes. ref SDS 70 ET68
200590 - ..
200591 - Report published by USACE calculates extra cost caused by rework to
200592 - correct management mistakes, ref DRP 2 4680, received on 971008.
200593 - ref SDS 8 1273
200594 -
200595 - An example on 990910, Kaiser failed to submit xrays for an
200596 - examination, ref SDS 40 3038; then switched medical ID cards, and
200597 - prepared a work order to take xrays for a different patient.
200598 - ref SDS 40 6305 The xray technician got mad, and that caused the
200599 - medical assistant, who prepared the work order, to make further
200600 - mistakes. I wound up with another patient's ID card, which caused
200601 - that person delay and frustration.
200603 - ..
200604 - On 991106 Steve nearly died due to incorrect treatment, because
200605 - his doctor failed to treat post-surgery complications when
200606 - requested by the patient. ref SDS 10 4980
200608 - ..
200609 - On 990603 cost of mistakes in auto service was reivewed.
200610 - ref SDS 23 0001
200612 - ..
200613 - On 981027 cost of mistakes in construction was reviewed.
200614 - ref SDS 18 9152
200616 - ..
200617 - Mistakes take root and grow in every industry, reported on 950327.
200618 - ref SDS 4 0200
200620 - ..
200621 - Mistakes are compounded by new realities of technology that cause
200622 - limited time due to information overload, reviewed on 980307 from Andy
200623 - Grove's book, ref SDS 15 3151, and the NWO... paper. ref OF 8 6056
200625 - ..
200626 - The report today shows that patients need to confirm communications,
200627 - as recommended in an article on 990719 that reports mistakes are
200628 - caused by errors in medical records. ref SDS 33 0846 and ref SDS 33
200629 - 4599
200630 -
200631 - [On 000207 doctors are pressed for time because meetings with
200632 - patients are scheduled every 15 minutes, so there is not enough
200633 - time to verify accuate communication. ref SDS 54 0788
200635 - ..
200636 - Medical work needs controls to reduce mistakes. ref OF 3 0627 On
200637 - 971008 US Army Corps of Engineers published report that Com Metrics
200638 - reduces mistakes that cause rework. ref DRP 2 4680
200640 - ..
200641 - On 990527 cultural resistance to improving management was cited,
200642 - ref SDS 22 1233, reflecting perspective on 961222. ref SDS 6 0866 On
200643 - 990505 need to change attitudes was explained, ref SDS 20 4732, later
200644 - supported on 990910. ref SDS 40 9130
200646 - ..
200647 - On 990628 sent letter to Morris, others on benefits of Communication
200648 - Metrics for personal medical support. ref SDS 25 0001
200650 - ..
200651 - On 940728 Doctor Kory Zipperstein reported SDS record of medcial
200652 - history improves conventional medical practice. ref SDS 3 0001
200654 - ..
200655 - On 990625 the idea of Common Administration using the Kaiser "Patient
200656 - Assistance" role was set out. ref SDS 24 0899 Every industry has work
200657 - practice standards that call for effective communication, but these
200658 - are not used because of limited time. ref SDS 24 4928,
200660 - ..
200661 - Andy Grove at Intel recognized that one form of effective feedback
200662 - loop in communication is taking copious notes, because the process of
200663 - writing out understandings reveals gaps in understanding that avoid
200664 - ambiguity of mental maps, as reviewed on 980307. ref SDS 15 3668
200666 - ..
200667 - Disrupting existing "feel good" management practice that causes
200668 - continual mistakes and bumbling, reviewed on 911123, ref SDS 1 1331,
200669 - by adding a business metric to communication in order to avoid
200670 - mistakes, is a "disruptive technology" that is resisted by strong
200671 - cultural forces cited on 990527, ref SDS 22 1233, as seen from the
200672 - record on 990910 visiting Kaiser Medical. ref SDS 40 9130
200673 -
200674 - [Later today discussed disruptive technology with Morris.
200675 - ref SDS 41 0270]
200676 -
200677 -
200678 -
200679 -
200680 -
200681 -
200682 -
200683 -
200684 -
200685 -
2007 -
Distribution. . . . See "CONTACTS"