CONTACTS 

SUBJECTS
Medical Mistakes Leading Causes Death Injury Greater than Automobile

2203 -
2203 -    ..
2204 - Summary/Objective
2205 -
220501 - Follow up ref SDS 6 0000, ref SDS 4 0000.
220502 -
220503 -
220504 -
220505 -
220506 -
220508 -  ..
2206 -
2207 -
2208 - Progress
2209 -
220901 - Communication Biggest Risk in Medical Practice for Health Care
220902 -
220903 - Millie received, ref DRT 1 0001, a letter from Pam with an attached
220904 - article on steps patients can take to reduce medical mistakes.
220905 - ref DRT 1 M139
220907 -  ..
220908 - Medical mistakes are mostly communication problems, ref SDS 0 4P61,
220909 - reflecting research on 931130 reporting Drucker's analysis that people
220910 - have given up because information density from faster technology
220911 - increases complexity, which overwhelms span of attention. ref SDS 1
220912 - 3851  This makes truth a moving target due to meaning drift, reported
220913 - on 960518. ref SDS 2 4488  Trying to improve medical practice by
220914 - adding intelligence support for communication is resisted by denial
220915 - that health care professionals need help turning information from
220916 - conversation into useful knowledge, reported on 990924. ref SDS 5 5576
220917 - These dynamics make...
220918 -
220919 -            communication the biggest risk in enterprise
220920 -
220921 - ...cited in POIMS. ref OF 4 IE6L
220923 -  ..
220924 - Title...
220925 -
220926 -        Patient Fact Sheet
220927 -
220928 -        20 Tips to Help Prevent Medical Errors
220929 -
220930 -            http://www.ahrq.gov/consumer/20tips.htm
220932 -  ..
220933 - AHRQ is the lead agency for research to improve the quality of health
220934 - care and reduce cost.  AHRQ sponsors and conducts research that
220935 - provides evidenced-based information on health care outcomes, quality
220936 - and cost.
220938 -  ..
220939 - Article is published by....
220940 -
220941 -        Department Health and Human Services
220942 -
220943 -        AHRQ Publication No. 00-PO38
220944 -
220945 -        Agency for Healthcare Research and Quaity
220947 -         ..
220948 -        September 2000
220950 -         ..
220951 -        Funding opportunities healthcare research are listed on....
220953 -  ..
220954 - AHRQ home page...
220955 -
220956 -            http://www.ahrq.gov/
220958 -  ..
220959 - Article says in part...
220960 -
220961 -    1.  Medical errors are one of the Nation's leading causes of death
220962 -        and injury. A recent report by the Institute of Medicine
220963 -        estimates that as many as 44,000 to 98,000 people die in U.S.
220964 -        hospitals each year as the result of medical errors. This means
220965 -        that more people die from medical errors than from motor
220966 -        vehicle accidents, breast cancer, or AIDS. ref DRT 1 0M7K
220968 -  ..
220969 - This supports reporting on the high cost of medical mistakes reviewed
220970 - on 990912 that found medical mistakes kill 3 times more people than
220971 - care, airplane, and train accidents combined. ref SDS 4 0001
220973 -  ..
220974 - Major cause of medical mistakes is failure to implement management
220975 - standards, reported case study on 020504. ref SDS 7 NS6F
220976 -
220977 -            [On 051103 study shows 34% of patients report experiencing
220978 -            medical mistakes. ref SDS 8 ET68
220979 -
220980 -            [On 080911 article Why Doctors Make Mistakes explains
220981 -            problems of busy doctors overwhelmed by hectic schedule
220982 -            rely on personal memory and conversation, do not have time
220983 -            for analysis to review patient history. ref SDS 12 U17Q
220985 -             ..
220986 -            [On 090314 1543 CALO project ended at SRI; possible follow
220987 -            on application to health care research. ref SDS 19 419M
220988 -
220989 -
220990 -
2210 -

SUBJECTS
Health Care Medical Mistakes Confused Complex Health Care System Cas

4703 -
470401 -  ..
470402 - Medical Errors Work Plan Not Comprehensive Not Implemented Delayed
470403 -
470404 -
470405 - Article continues...
470406 -
470407 -    2.  What are Medical Errors? ref DRT 1 XL8N
470409 -         ..
470410 -        Medical errors happen when something that was planned as a part
470411 -        of medical care doesn't work out, or when the wrong plan was
470412 -        used in the first place. Medical errors can occur anywhere in
470413 -        the health care system:
470414 -
470415 -              •  Hospitals.
470416 -              •  Clinics.
470417 -              •  Outpatient Surgery Centers.
470418 -              •  Doctors' Offices.
470419 -              •  Nursing Homes.
470420 -              •  Pharmacies.
470421 -              •  Patients' Homes.
470422 -
470423 -
470425 -  ..
470426 - Communication Biggest Cause Medical Mistakes
470427 - Modern Health Care Rising Complexity Communication Medical Errors
470428 - Complex Case Management Multiple People Organizations High Risk Errors
470429 -
470430 -
470431 -    3.  Errors can involve:, ref DRT 1 O99K
470432 -
470433 -              •  Medicines.
470434 -              •  Surgery.
470435 -              •  Diagnosis.
470436 -              •  Equipment.
470437 -              •  Lab reports.
470439 -         ..
470440 -    4.  They can happen during even the most routine tasks, such as
470441 -        when a hospital patient on a salt-free diet is given a
470442 -        high-salt meal.
470444 -         ..
470445 -        Most errors result from problems created by today's complex
470446 -        health care system. But errors also happen when doctors and
470447 -        their patients have problems communicating. ref DRT 1 0O5O
470449 -  ..
470450 - Medical mistakes cited in national reporting on 990912, ref SDS 4
470451 - 0960, are caused by problems communicating due to rising complexity,
470452 - explained in letter on 990924. ref DIP 2 FPSE  Complexity of health
470453 - care overwhelms span of attention with hectic schedules that increase
470454 - meaning drift and false knowledge, explained in POIMS. ref OF 4 049O
470455 - Problems rise from difficulty understanding and following up
470456 - communications becasue people cannot maintain a well ordered record,
470457 - explained in NWO. ref OF 12 RO6G  Medical practice needs a new role
470458 - and tools for patient assistance, explained on 990924. ref SDS 5 2955
470459 -
470460 -            [On 080911 article reports many medical mistakes occur from
470461 -            mental errors by doctors involving communication.
470462 -            ref SDS 12 PD7F
470464 -             ..
470465 -            [On 090130 urgent treatment needed quickly delayed by
470466 -            communication glitch. ref SDS 16 AY8Q
470467 -
470468 -
470469 -
470471 -  ..
470472 - Communication Doctor Patient Fails Causes Case Management Failure
470473 - Treatment Fails When Patients Don't Understand Scope of Care
470474 -
470475 -
470476 - Article continues...
470477 -
470478 -    5.  For example, a recent study supported by the Agency for
470479 -        Healthcare Research and Quality (AHRQ) found that doctors often
470480 -        do not do enough to help their patients make informed
470481 -        decisions. Uninvolved and uninformed patients are less likely
470482 -        to accept the doctor's choice of treatment and less likely to
470483 -        do what they need to do to make the treatment work.
470485 -  ..
470486 - This aligns with a study reported on 991221 that found patients are
470487 - not adequately informed by doctors in nine out of 10 decisions.  Key
470488 - information was missing from discussions 91% of the time. ref SDS 6
470489 - 0001
470490 -
470491 -            [On 090209 Millie's letter asks about remedies of side
470492 -            effects from radiation and hyperthermia treatments.
470493 -            ref SDS 17 745R
470495 -             ..
470496 -            [On 090218 request for work plan and explanation of
470497 -            treatment scope, and expectations. ref SDS 18 TH5W
470498 -
470499 -
470500 -
470501 -
470502 -
470503 -
470504 -
4706 -

SUBJECTS
Health Care Medical Mistakes Confused Complex Health Care System Cas

7203 -
720401 -  ..
720402 - Doctor Patient Partnership Improves Care Prevents Mistakes Saves Time
720403 -
720404 -
720405 - Article continues...
720406 -
720407 -    6.  The single most important way you can help to prevent errors is
720408 -        to be an active member of your health care team. ref DRT 1 0113
720410 -         ..
720411 -        That means taking part in every decision about your health
720412 -        care.  Research shows that patients who are more involved with
720413 -        their care tend to get better results.  Some specific tips,
720414 -        based on the latest scientific evidence about what works best,
720415 -        follow. ref DRT 1 KT4K
720417 -  ..
720418 - This solution fits the model posed by the Kaiser Healthwise Handbook,
720419 - calling for a doctor and patient partnership, reported on 990625.
720420 - ref SDS 3 4185
720422 -  ..
720423 - Written communication with feedback through email improves accuracy to
720424 - reduce mistakes, also, called out by Kaiser's Healthwise handbook.
720425 - ref SDS 3 3960
720426 -
720427 -            [On 060106 Kaiser email system paralyzes productivity
720428 -            eviscerates doctor patient communication. ref SDS 9 1O8F
720430 -  ..
720431 - Article continues...
720432 -
720433 -    7.  Doing surgery at the wrong site (for example, operating on the
720434 -        left knee instead of the right) is rare. But even once is too
720435 -        often. The good news is that wrong-site surgery is 100 percent
720436 -        preventable. The American Academy of Orthopaedic Surgeons urges
720437 -        its members to sign their initials directly on the site to be
720438 -        operated on before the surgery.
720440 -  ..
720441 - Problems of doing surgery on the wrong leg, arm, etc. was reported on
720442 - 990912.
720443 -
720444 -
720445 -
720447 -  ..
720448 - Questions Verify Diagnosis Treatment Plan Align Patient History
720449 -
720450 -
720451 - Article continues...
720452 -
720453 -    8.  Speak up if you have questions or concerns.
720454 -
720455 -        You have a right to question anyone who is involved with your
720456 -        care.
720458 -  ..
720459 - Aligns with Kaiser's Healthwise Handbook calling for doctors to review
720460 - patient records to verify accurate understanding of communication on
720461 - case management. ref SDS 3 5740  Similarly, the Healthwise Handbook
720462 - provides patient access to the medical chart and all records on
720463 - patient care.  Kaiser calls for a "ping pong" feedback loops for
720464 - accurate patient history that prevents medical errors. ref SDS 3 3960
720465 -
720466 -
720467 -
720468 -
720469 -
720471 -  ..
720472 - Case Management Comprehensive Responsiblity Authority Direct Work
720473 -
720474 -
720475 -    9.  Make sure that someone, such as your personal doctor, is in
720476 -        charge of your care.
720478 -         ..
720479 -        This is especially important if you have many health problems
720480 -        or are in a hospital.
720482 -  ..
720483 - Nominally, the primary care physician has responsibility for
720484 - comprehensive case management as the patients single point of contact
720485 - with authority to direct the work in time to be effective.
720486 -
720487 -            [On 070927 Kaiser's EOC section 2 provisions implement HHS
720488 -            requirements published by AHHQ for patients to have a
720489 -            single point of contact to be in charge of accomplishing
720490 -            case management effectively. ref SDS 10 WS6M
720492 -             ..
720493 -            [On 081112 Kaiser's representative in the Expedited Claims
720494 -            Department advised that Kaiser is lawfully required to
720495 -            implement doctor's orders for patient care. ref SDS 14 PR35
720497 -  ..
720498 - In practice, doctors come under a lot of political pressure not to
720499 - exercise authority in order to avoid social conflict with colleagues
720500 - and reprisals from superiors, explained on 090924.
720502 -             ..
720503 -            [On 081024 doctor asks Millie to coordinate with CT
720504 -            department on scope of test, because directing the work
720505 -            across departments is stressful. ref SDS 13 P67O
720507 -             ..
720508 -            [On 081219 doctoe asks Millie to coordinate with UCSF on
720509 -            getting written recommendations for follow on treatment.
720510 -            ref SDS 15 E84J
720512 -             ..
720513 -            [On 081112 after having ordered Millie's care on referral
720514 -            to UCSF performing the duty to prescribe treatment under
720515 -            EOC section 2, Millie's doctor called later under durress
720516 -            of superiors and attempted to withdraw the prior medical
720517 -            orders. ref SDS 14 RZ6K
720518 -
720520 -  ..
720521 - Records Management Essential to Coordinate Comprehensive Timely Care
720522 -
720523 -
720524 -   10.  Make sure that all health professionals involved in your care
720525 -        have important health information about you.
720527 -         ..
720528 -        Do not assume that everyone knows everything they need to.
720529 -
720530 -
720531 -
720533 -  ..
720534 - Patient Assistant Critical Health Care Accurate Communication
720535 -
720536 -
720537 -   11.  Ask a family member or friend to be there with you and to be
720538 -        your advocate (someone who can help get things done and speak
720539 -        up for you if you can't).
720541 -         ..
720542 -        Even if you think you don't need help now, you might need it
720543 -        later.
720545 -  ..
720546 - Aligns with Kaiser Healthwise Handbook reviewed on 990625 calling for
720547 - assistance to watch out for patient interests. ref SDS 3 JY9J
720548 -
720549 -            [On 080318 some people resist getting help with meetings,
720550 -            rely on 2 x 3 inch shirt pocket diary to manage complex
720551 -            patient history. ref SDS 11 9G6U
720553 -             ..
720554 -            [On 080911 article reports many medical mistakes occur from
720555 -            mental errors by doctors involving communication.
720556 -            ref SDS 12 PD7F
720558 -         ..
720559 -   12.  For example, treatment recommendations based on the latest
720560 -        scientific evidence are available from the National Guidelines
720561 -        Clearinghouse at
720562 -
720563 -           http://www.guideline.gov.
720565 -         ..
720566 -   13.  Ask your doctor if your treatment is based on the latest
720567 -        evidence.
720568 -
720570 -         ..
720571 -   14.  Linda Collin<BR>
720572 -        North Valley Division Account Services Department<BR>
720573 -        350 Salem Street, Chico, CA 95928<BR>
720574 -        751-4245 or 530-896-4245<BR>
720575 -        Fax: 751-4292 or 530-896-4292
720576 -
720578 -  ..
720579 - Contact Linda about SDS support for her article.
720581 -  ..
720582 - Bill Wagoner presents a model of someone regularly contacting
720583 - potential customers for SDS, and other support.
720584 -
720585 -
720586 -
720587 -
720588 -
720589 -
720590 -
720591 -
720592 -
720593 -
720594 -
720595 -
7206 -