Podcasts about diagnostic error

Welcome back to The Peds NP Acute Care Faculty series! This series was created and peer-edited by national leaders in acute care PNP education collaborating with one another to meet the needs of our current and future colleagues. In the push for competency-based education where faculty verify the skills of what a student can do, rather than their knowledge, our series focuses on the application of didactic content with a practical approach so that you can learn nuances of clinical skills before you reach the bedside.    This episode guides the novice pediatric provider on creations of an acute care differential diagnosis. It starts with a story about a Southerner in a snowstorm and the unfortunate car problem that resulted from an unexpected guest in the engine. A clear parallel ties the mechanic's diagnosis with a few amateur onomatopoeias (“clunk, clunk, clunk”) with the skills needed to form illness scripts and develop differentials. A brief case study on an adolescent with acidosis introduces the idea of broad differential formation and the importance of a complete evaluation before diagnoses are eliminated. Medical decision-making is difficult, and a systematic approach to differential diagnosis formation is essential. The episode uses simple examples to help listeners apply the concepts and form a differential in real time. The discussion covers the importance of careful accrual of information, initial differential creation using a systematic approach, how to narrow your differential based on key findings of the assessment, and how to approach an open-ended differential honestly with families while avoiding cognitive bias. With the understanding that, “disease exists on a continuum that evolves and we see the patient at a snapshot in time,” the episode offers a step by step guide on how to build a differential. Classic mantras of The Peds NP are finally explained and tied to the development of your acute care differential. Every novice needs to listen to this episode before ever stepping foot in the clinical setting to be prepared for diagnostic reasoning and the process of narrowing your differential.   This episode was peer reviewed by The Peds NP faculty series peer review team. You can read about our novel and scholarly approach to peer review, review our faculty lineup, and learn more about the series, competency mapping, references, and show notes at www.thepedsnp.com. There was no financial support or conflicts of interest to report. Follow me on Instagram @thepedsnppodcast.  Email me at thepedsnp@gmail.com.  Remember that this isn't just a podcast, you're listening for the kids.   Authors (alphabetical):  Aimee Bucci DNP, APRN, CPNP-AC, Becky Carson, DNP, APRN, CPNP-PC/AC, & Dani Sebbens, DNP, CPNP-PC/AC   References: Balogh, E. P., Miller, B. T., Ball, J. R., Committee on Diagnostic Error in Health Care, Board on Health Care Services, Institute of Medicine, & The National Academies of Sciences, Engineering, and Medicine (Eds.). (2015). Improving Diagnosis in Health Care. National Academies Press (US). Brennan, M.M (2020). Teaching strategy 1: cultivating diagnostic decision-making with problem based learning: from most likely to least likely. Innovative Strategies in Teaching Nursing. doi: 10.1891/9780826161215 Carson, R. A., & Lyles, J. L. (2024). Cognitive Bias in an Infant with Constipation. The Journal of pediatrics, 113996. Advance online publication. https://doi.org/10.1016/j.jpeds.2024.113996 Hammond, M. E. H., Stehlik, J., Drakos, S. G., & Kfoury, A. G. (2021). Bias in Medicine: Lessons Learned and Mitigation Strategies. JACC. Basic to translational science, 6(1), 78–85. https://doi.org/10.1016/j.jacbts.2020.07.012Marshall, T. L., Rinke, M. L., Olson, A. P. J., & Brady, P. W. (2022). Diagnostic Error in Pediatrics: A Narrative Review. Pediatrics, 149(Suppl 3), e2020045948D. https://doi.org/10.1542/peds.2020-045948D Marshall, T. L., Rinke, M. L., Olson, A. P. J., & Brady, P. W. (2022). Diagnostic Error in Pediatrics: A Narrative Review. Pediatrics, 149(Suppl 3), e2020045948D. https://doi.org/10.1542/peds.2020-045948D Smith, S.K., Benbenek, M.M., Bakker, C.J., & Bockwoldt, D. (2022). Scoping review: diagnostic reasoning as a component of clinical reasoning in the U.S. primary care nurse practitioner education. Journal of Advanced Nursing, 78:3869-3896. doi: 10.1111/jan.15414  

Dr. Art Papier believes we are focusing on the wrong questions in medicine, and for the best care of patients, we need augmented intelligence. Dr. Art Papier, MD is Chief Executive Officer and co-founder of VisualDx. He is a dermatologist, medical informatics expert, and Associate Professor of Dermatology and Medical Informatics at the University of Rochester School of Medicine and Dentistry. Dr. Papier graduated from Wesleyan University, the University of Vermont College of Medicine, and completed graduate medical training at the University of Rochester Medical Center. His interests span healthcare costs as related to clinical accuracy, clinical decision support systems, diagnostic error reduction, cognitive error, medical education, and empowering patients. 

Dr. Jason Lee has written and presented on how we think, cognitive bias in medical diagnosis, and errors in the pathologic pathway of a biopsy from clinic to final report. The latter was recently published in the Journal of Cutaneous Pathology.  It is truly a pleasure to hear Dr. Lee talk with ease about errors, including his own. Dr. Jason B. Lee, MD is Professor, Director of the Jefferson Dermatopathology Center, Director of the Dermatopathology Fellowship, and Director of the Jefferson Pigmented Lesion Clinic at Jefferson Medical College of Thomas Jefferson University. He interned at the University of California, Irvine and then did his residency and fellowship at Thomas Jefferson University Hospitals. He has a recent article in the Journal of Cutaneous Pathology that focuses on error in the pathologic diagnostic pathway. 

In this episode, Dr. Heather Murray, from Queen's University Department of Emergency Medicine presents the landscape of diagnostic errors in emergency medicine from the perspective of why they might occur, what can be done when they happen, and how we might minimize them in the future.    CONTACTS X - @AlwaysOnEM; @VenkBellamkonda YouTube - @AlwaysOnEM; @VenkBellamkonda Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch Email - AlwaysOnEM@gmail.com   REFERENCES ARHQ report and responses: December 2022, AHRQ (Agency for Healthcare Research and Quality) released a systematic review on diagnostic error in the ED. https://effectivehealthcare.ahrq.gov/sites/default/files/related_files/cer-258-diagnostic-errors.pdf Letter from many ED organizations: Multi-Organizational Letter Regarding AHRQ Report on Diagnostic Errors in the Emergency Department December 14, 2022 Published critical appraisal of report: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10121120/pdf/ms120_p0114.pdf JAMA commentary Feb 2023 “Misdiagnosis in the ED: Time for a System Solution” Misdiagnosis in the Emergency Department: Time for a System Solution | Health Care Safety | JAMA Recovering from error: ARHQ summary on recovery after error Second Victims: Support for Clinicians Involved in Errors and Adverse Events | PSNet ARHQ Commentary – after error:How Do Providers Recover From Errors? | PSNet Clinician Peer Support Program after adverse events – implementation Supporting Clinicians after Adverse Events: Development of a Clinician Peer Support Program - PMC Scott SD, Hirschinger LE, Cox KR, McCoig M, Hahn-Cover K, Epperly KM, Phillips EC, Hall LW. Caring for our own: deploying a systemwide second victim rapid response team. Jt Comm J Qual Patient Saf. 2010 May;36(5):233-40. Caring for our own: deploying a systemwide second victim rapid response team   General resources on Diagnostic Error: Schiff JAMA Network Open 2021Characteristics of Disease-Specific and Generic Diagnostic Pitfalls: A Qualitative Study | Health Policy | JAMA Network Open Monteiro et al. 2020 Review “The enduring myth of generalisable skills.” https://asmepublications.onlinelibrary.wiley.com/doi/full/10.1111/medu.13872 Book – Improving Diagnosis in Health Care (chapter 9) The Path to Improve Diagnosis and Reduce Diagnostic Error   Cognitive biases: MDs were asked to reflect on a serious error and given some education on cognitive biases: Watari, T.; Tokuda, Y.; Amano, Y.; Onigata, K.; Kanda, H. Cognitive Bias and Diagnostic Errors among Physicians in Japan: A Self Reflection Survey. Int. J. Environ. Res. Public Health 2022, 19, 4645. Cognitive Bias and Diagnostic Errors among Physicians in Japan: A Self-Reflection Survey Anchoring Bias and strategies for overcoming: Anchoring Bias With Critical Implications | PSNet "Give me a break!" A systematic review and meta-analysis on the efficacy of micro-breaks for increasing well-being and performance: Albulescu P, Macsinga I, Rusu A, Sulea C, Bodnaru A, et al. (2022) "Give me a break!" A systematic review and meta-analysis on the efficacy of micro-breaks for increasing well-being and performance. PLOS ONE 17(8): e0272460. "Give me a break!" A systematic review and meta-analysis on the efficacy of micro-breaks for increasing well-being and performance | PLOS ONE   Better teams in EM: Purdy E, Borchert L, El-Bitar A et al “Psychological safety and Emergency Medicine team performance: a mixed methods review.” EM Australasia 2023;35:456-465 Psychological safety and emergency department team performance: A mixed‐methods study - Purdy Ottawa M+M rounds framework: Enhancing the Quality of Morbidity and Mortality Rounds: The Ottawa M&M Model - Calder - 2014 - Academic Emergency Medicine - Wiley Online Library   Selected references for artificial intelligence in medicine: AI chatbot in JAMA Internal Medicine Comparing Physician and Artificial Intelligence Chatbot Responses to Patient Questions Posted to a Public Social Media Forum | Health Informatics | JAMA Internal Medicine AI in Health Care NEJM podcast Is Medicine Ready for AI? — ITT Episode 6 | NEJM AI clinical prediction (systematic review 2022) Artificial Intelligence for the Prediction of In-Hospital Clinical Deterioration: A Systematic Review - PMC Lee P, Bubeck S, Petro J. Benefits, limits and risks of GPT-4 as an AI chatbot for medicine. NEJM 2023;388:1233-1239 Benefits, Limits, and Risks of GPT-4 as an AI Chatbot for Medicine | NEJM  

Join me in my conversation with Dr. Rebecca Miller who has extensive experience in the healthcare arena, both as a highly trained psychiatrist and as a patient. We touch on a trip to the Pyrenees, parenthood, and cogntive bias as pertaining to the misdiagnosis of early onset Parkinson's disease. Dr. Rebecca Miller, PhD attended Barnard College-Columbia University as an undergraduate, received an MA and PhD at Long Island University in Clinical Psychology, and completed pre- and post-doctoral training at Yale University School of Medicine. She has received the Goldberg Leadership in Education from the American Psychological Association in 2019, and she is currently an Associate Professor Psychiatry as well as the Director of Peer Support and Family Initiatives at the Connecticut Mental Health Center. She is a strong believe in the power of the patient voice and has written on the lived experience with Parkinson's disease as well as the lived experience of safe disclosure for mental health professionals. She was diagnosed with Parkinson's at age 39 although first identified symptoms as early as age 26. For more information, visit https://www.rebeccamillerphd.com/. Links to articles on better care in the hospital, parenting with Parkinson's, and the body as public property for commentary.

The JournalFeed podcast for the week of March 6-10, 2023.These are summaries from just 2 of the 5 article we cover every week! For access to more, please visit JournalFeed.org for details about becoming a member.Diagnostic Error Spoon FeedDiagnostic errors in the ED occur at rates similar to those in other clinical settings. Not all errors have human causes, and not all are inevitable – this article suggests systems-level opportunities for improvement.MDI for Croup Spoon FeedEpinephrine administration via metered-dose inhaler (MDI) for the treatment of croup in children may be a safe and effective alternative to nebulization.

Our guest today is Dr. Art Papier, co-founder and CEO at VisualDx. A dermatologist, Dr. Papier has a particular interest in the visual and graphical representation of diagnosis and reducing diagnostic error. In line with this goal, he is focused on transforming medical care to include the use of information technology at the time of decision-making. Resources: VisualDx: https://www.visualdx.com/ VisualDx Success Stories: https://www.visualdx.com/success-stories/ Dr. Art Papier on LinkedIn https://www.linkedin.com/in/art-papier-md-a94b256/ Sponsor: This episode is brought to you by the MGMA Emerald Card* (https://about.mgma.cards/), the premier card built specifically for medical practice owners. With 1.5% cashback, paid MGMA dues bonus, no impact on personal credit, and vendor rebates, it's tailor-made to medical practices. So what are you waiting for? Go to https://about.mgma.cards/ to get started today. *Conditions apply. Subject to approval. Mercantile Financial Technologies, Inc. is a financial technology company, not a bank. The MGMA Credit Cards are issued by Hatch Bank pursuant to a license from Mastercard. Mastercard is a registered trademark, and the circles design is a trademark of Mastercard International Incorporated. Review the cardholder agreement at https://about.mgma.cards/terms. If you would like additional tools and resources related to medical practice leadership email us at podcasts@mgma.com. Thank you again for taking the time to listen to MGMA's Insights podcast. If you have opportunities you'd like to share with the MGMA audience, go to www.mgma.com/marketing-with-mgma/advertise to find out how you can connect with the MGMA audience.

For this episode, Drew and Andy are joined by Brian Acunto, DO, EJD, to discuss the topic of diagnostic error in EM. Don't forget we are the official podcast of the American College of Osteopathic Emergency Physicians. Visit acoep.org to learn more about this organization and how you can join today!

Related CMPA Perspective article:Can intraoperative decisions be diagnostic errors?https://www.cmpa-acpm.ca/en/advice-publications/browse-articles/2020/can-intraoperative-decisions-be-diagnostic-errors

Guests: Kayla Simiele, RN and Amanda Johnshoy, MSN, RN Host: Timothy Morgenthaler, M.D. @DrTimMorg Specimens provide a crucial chain of evidence in the practice of medicine. Unfortunately, labeling errors and lost specimens do occur, unleashing a host of downstream challenges including delayed or incorrect treatment. In the podcast, guests from the Department of Nursing describe their efforts to reduce specimen errors in a Mayo Clinic surgical practice. They discuss how their efforts, using DMAIC (Define, Measure, Analyze, Improve and Control) methodology and other quality improvement techniques, significantly reduced specimen errors and discuss key learnings being shared with other surgical practices at Mayo Clinic. Find out more about Mayo Clinic's Quality program at https://www.mayoclinic.org/about-mayo-clinic/quality/. Connect with us on Twitter or Facebook using #mayokeyintoquality or at https://www.facebook.com/MayoClinic https://twitter.com/MayoClinic  

In this episode of GENEYE Pod, host Dr Jacqueline Beltz talks with Associate Professor Carmel Crock, OAM, Emergency Physician and Director of the Emergency Department at The Royal Victorian Eye and Ear Hospital about diagnostic error and medical professionalism. Medical Professionalism is a complex topic.  At first glance it can seem straight forward but professionalism is difficult to define.  Professionalism is important within medicine for our patients', our own and our workplace experiences, but it is also important for clinical outcomes.    We're more likely to make mistakes if we behave unprofessionally.  Professionalism in the medical setting is also associated with increased patient satisfaction, trust, and adherence to treatment plans;  fewer patient complaints and reduced risk of litigation.  Professionalism has also been associated with physician excellence.In this episode, Dr Beltz talks about why professionalism should be considered a buildable skill rather than a personality trait.  She discusses some of the concepts linking unprofessional behaviours to diagnostic errors and suggests that this is not only bad for our patients but for us too.  Dr Beltz and Associate Professor Crock take the discussion further, with particular focus on strategies to improve knowledge, skills and culture relating to diagnostic error.  They discuss why management of diagnostic errors is so difficult and why professionalism is critical.  They also discuss management strategies and ways to improve these skills, highlighting the importance of positive role modelling.At GENEYE, we care about ourselves and each other, so we can care for our patients.  We can't even begin to truly think we will serve our patients adequately if we don't care about ourselves.  Associate Professor Crock and Dr Beltz conclude their discussion with conversation about medical culture and wellbeing – what they have seen improve and what they hope will come next.___________________________________________________________________________Acknowledgments Jacqueline Beltz and GENEYE would like to thank The Mind Room, Collingwood for supporting our program and allowing us to record in their studio.   Thank you also to Professors Ian Incoll and Debra Nestel from University of Melbourne Masters of Surgical Education program for their ongoing support, teaching and encouragement.GENEYE POD is written, and hosted by Jacqueline Beltz and produced with the help of Nick Green from CORP COMM.We would like to acknowledge the people of the Kulin Nations who are the traditional custodians of the land on which this podcast was recorded.  We would also like to pay our respects to Elders past, present and emerging and to any Aboriginal and/or Torres Strait Islander people who might listen to this podcast.  ___________________________________________________________________________  Further resources:GENEYE   https://www.geneye.org.auSociety to improve diagnosis in medicine (SIDM) https://www.improvediagnosis.orgAustralasian Diagnostic Error in Medicine Conference https://www.ashm.org.au/Conferences/conferences-we-organise/AusDEM-Conference/

RVTS recently hosted the 3rd annual RVTS Grand Round Webinar.  We were delighted to be joined by Art Nahill and Nic Szecket from IMReasoning, amongst others,  who discussed a case in the form of a “cognitive autopsy” - with all the benefits of hindsight.  The discussion highlights that diagnostic errors occur surprisingly commonly!

The Sheridan family knows first hand the devastation caused by medical error. Sue and Pat’s newborn son Cal, due to misdiagnosing his jaundice, was brain damaged. Cal now lives with significant cerebral palsy. Years later, Pat was correctly diagnosed with cancer, but for 6 months a pathology report failed to be communicated to the doctor or Pat. Pat died of cancer at age 45. In this episode of Medical Error Interviews, I chat with documentary filmmaker Mike Eisenberg about his film To Err Is Human and about the Sheridan family and the state of patient safety. Mike is the son of late patient safety pioneer Dr John M Eisenberg, and as you will hear Mike say, when he started looking into medical errors and patient safety, he felt compelled to carry on his father’s legacy. Mike Eisenberg Show Notes Following his Father's footsteps   0:07:00 Mike was born in Philadelphia - childhood mostly in Maryland - but as a child was not interested in health care, even though his father was a patient safety advocate - as documentary filmmaker he wanted to tell stories otherwise not seen - fiction is harder and more expensive to make into film - the documentary path led down the path to make "To Err is Human" 0:09:30 About 3.5 years ago it started with a short film on AHRQ: Agency for Health Research and Quality, the organization Mike's father started and was the Director until he passed away in 2002 - there was annual debates over AHRQ's budget and attempts to slash it - but AHRQ has far less money they should given their role 0:10:30 Started the documentary by driving to DC, pay out of pocket, and interview his father's old colleagues about AHRQ's role that the public knows nothing about - themes of medical error, patient safety and improving care emerged - it was evident to Mike that conversation was no longer being had - if felt to Mike it was his responsibility to carry on his father's work 0:11:30 We, including his production partners Matt Downe and Kailey Brackett try to stay positive in tone and show what happens when people take this seriously - focus on the process to make things better 0:12:45 Report in late '90s titled To Err is Human, Building a Safer System - a report that used research that determined how bad medical error was - the data was shocking - it said 44,000 to 98,000 died each year from medical error - that was brand new concept, made new headlines, President Clinton said it would be tackled 0:14:00 At the time, those numbers were questioned - but today one study, Marty Macquarrie out of John Hopkins that says 251,000 die each year - and John James's study that says between 240,000 and 440,000 die each year from medical error - hard to quantify because CDC (Centre for Disease Control) doesn't have a box to tick for 'death by medical error' - even conservative estimates have medical error as 3rd leading cause of death 0:16:00 We compare how many plane crashes, 7 or 8, would happen each day to equal medical error deaths each day - a staggering number, almost the same as the opioid epidemic - the important question is not accuracy of numbers, but how to get accurate numbers     The Sheridan family and medical errors   0:18:00 There is not a consensus around medical error death numbers - sometimes people die at home from hospital errors - part of the reason we've not seen more solutions is that the public, especially Americans, have been trained to treat the medical system: that physicians don't make mistakes, they are right all the time 0:19:45 The real reason we've not seen change in patient safety is because physicians have not embraced the patient in this process - some health care systems have, they visited over 250 health care systems - many of them doing interesting things to help curb error, but only a few have really engaged the patient 0:21:00 If a Hospital engages patients in a patient safety process, then the Hospital is admitting it makes mistakes, and that admission is considered guilt - but Med Star Health, especially out of Georgetown, show promise: they had a public facing explanation of an error that was prevented - great message that most of these errors are preventable 0:22:30 It is easy to say to public we are humans too and make mistakes, and most are not egregious or intentional - most hospital surgeries have a practice called 'stop the line' and reasses if things are organized correctly, a bean counter will say it is not efficient and costs money, but it costs less then lawsuits 0:24:15 Regarding body cameras worn by physicians for patient safety, Mike considered including that aspect but thought it was too touchy subject - solutions for other societal problems can be embraced by health care - aviation is the most obvious, they interviewed Sully Sullenburger of the water landing in the Hudson River - vital health care takes a look outside its own walls 0:25:45 In Toronto we found a surgical team using video and other data to show when errors are most likely to occur and to use that data for better safety - 'hand offs' to other staff is obvious time things can go wrong 0:27:45 Improving patient safety is more than preventing law suits - the real 'bottom line' is about lives not profit - we expect health care to do what it is supposed to do and not cause new problems - what's important is communication with the patient 0:29:15 One of the stories in our film is about Sue Sheridan - her family experienced 2 medical errors - the 1st was her son Cal who has cerebral palsy and got that at 5 days old because of a small over sight by not performing an available and cheap test when he was born with jaundice - the other case is about the father Pat who was diagnosed with cancer - they thought it was benign but sent sample for pathology examination     Aviation Culture vs Medical Culture   0:30:15 The results showed it was malignant, dangerous and needed to be removed - but those results didn't get through for 6 months because it was an over looked fax - so Pat didn't get treatment and died of cancer - but what doesn't go on the death certificate is that he lost 6 months of treatment 0:31:30 Organizations like the Society for Diagnostic Error in Medicine (SDIM) is leading the charge on diagnostic errors 0:33:00 The biggest difference between airline industry culture and medical industry culture is the lack of transparency of the latter - recently an airplane window cracked and fell off and sucked a woman out the window, that was the 1st aviation accident that lead to a death in years - studies have found that most plane tragedies are not accidents 0:34:00 Recently Boeing had 2 large plane crashes and they've been open about determining what went wrong and how to fix it - the same thing should happen in health care 0:35:00 In aviation pilots have to re-take their test every 5 years to prove their competence - don't do that with driving cars, just give licenses when people are 17 and assume they'll good for the rest of their life - same thing with health care - we need to be honest about where health care is weak and where it can be improved 0:36:30 In aviation, airlines work together globally to improve safety for all airlines - but this is not the practice in most hospitals - but there are exceptions that share their research and date like Inter Mountain Heath Care in Utah, and some in Boston that have embraced imperfection - when an error happens they gather the team to learn how to prevent it in the future, as opposed to how avoid bad PR (public relations), or blaming someone and firing them - that's not how you fix the problem 0:38:15 In the documentary, Sue's family engaged in litigation, they 'won' in one instance of medical error, but not in the other - Mike chose not to focus on the litigation angle in the documentary - for the medical error to Sue's son, they did not get a resolution - Sue has turned her entire life into advocacy - one of her achievements is that the test her son should have received - bilirubin - is now a requirement 0:39:45 For Sue's husband's medical error - been about 18 years since her husband died, and the hospital recently had a screening of the documentary and a panel discussion afterward - the first time the hospital had openly discussed the case with its own staff - the pathologist had told Sue that it was not his responsibility to make sure the info he sent got through to the receiver     Physicians have highest suicide rate   0:41:45 The US will have a shortage of physicians by 2024 often due to burnout - because they are also enterpreneurs - they have one of the most challenging jobs in the world 0:43:00 Physicians have highest suicide rate of all professions - rampant in physician culture, especially clinicians - Mike's friends that are doctors are over worked and its scares him - they needed to be treated right - but its hard to expect humans to be perfect all the time when they are not treated that way - when things go wrong, the hospital worries more about its image then the people, its a systems vs people problem - it promotes volume and that is not conducive to reliability 0:45:30 Mike calls upon patients to be a voice, its not just a hospital problem - don't have to go to school for many years, just need to listen and look - can avoid a lot of these mistakes if they listened to patients, and patients felt empowered to engage 0:47:00 Re physician suicide, it is an individual choice - wouldn't be surprised if financial problems are a factor - many start with 6 figure deaths, have families, and witness trauma every day, its a tough job - Mike has screened his film a lot in hospitals and he hears staff worried about losing job if point out errors - there is heirarchy in health care that is not healthy - old gaurd is not embracing new reality 0:50:00 One hospital claimed they had solved physician burnout by mandating that there was at least 6 hours between shifts - but that is still not reasonable - lessen to learn is suicide is individual, but common is that they feel their profession is not respected, appreciated - the message is that its been working for 70 years, why change now - but now is the time to change to take patient safety seriously 0:52:00 Fixing patient safety is about how care is delivered, and how we treat health care workers 0:53:00 In aviation, they do not permit pilots to fly if they haven't had a specific number of hourss of sleep, or if they've had even one drink of alcohol - some hospitals have similar standards, but why is that not a federal mandate? The Agency for Healthcare and Research Quality (AHRQ) is important to learn where to get better - but not much done with that info because they are underfunded but could cause huge change 0:55:00 This is not new issue, its been around for 20 years - need to have discussions about access to care, about diversity and care - but they are only improved if thought from a patient safety perspective     Media and its messages   0:56:15 Aviation has done it well because they've collaborated globally, but in the US hospital are autonomous and its hard to develop a plan that all will follow - while aviation has an organization that investigates crashes, that doesn't exist in health care - why is that not happening in health care? Because one person dies at a time. 0:58:00 In aviation, they 2 or 3 hundred at a time and those stories are on all the front pages - but when someone dies from communication breakdown there isn't the same collective impact or response - it boggles the mind 0:59:00 Since his documentary released, seen a documentary on HBO called Bleed Out, made by a comedian who tells about his family's experience with medical error over the years - also Bleeding Edge on Netflix about tthe FDA's lackadaisical approval of medical devices - 3 documentaries coming out in 1 year is progress - but how to make progress on the national stage? Mike working collaboratively on a project to put patient safety on the map 1:01:30 Media has a responsibility in patient safety too - Mike says every day there are 4 or 5 stories on gun violence in Chicago, where he lives - and that problem persists despite local government action to fix it - in health care errors will always occur, but can learn from errors to prevent future harm - but to fix the problem requires engaging the public 1:03:15 Media is hugely responsible for what people care about - the media has all the power about what people care about - essentially telling the political atmosphere what it should care about - Americans choose what they want to protest about - we need a better way to show the scope and scale of medical error without blaming doctors and nurses - there is no villain in patient safety - malpractice is different from patient safety 1:05:00 We need a villain, somebody to blame - last year at Vanderbilt, a nurse was thrown under the bus for making an error that resulted in death, but it was actually a system failure that allowed her humanness to make an error, it was not her fault - instead of the hospital changing the system, they throw an employee under the bus, and she went to jail - then we wonder why people don't report errors when they see them 1:06:45 A culture shift in health care is needed, and it must come from the top - by working together we can send a message to 'the top' to make a change 1:08:00 Most patients want to be treated with honesty and transparency and will work together if something goes wrong - but that's not usually how it happens, it is usually a cover up, or denial, or this is how health care works and sucks to be you - but a culture of lawsuits has emerged as the way to get info out of hospitals - its not about money for most of these people       Less money, more transparency   1:09:15 In Sue's case, she sued for less money in exchange for greater transparency - we should get away from lawsuit culture and move toward working together 1:10:20 Mike has been fortunate to travel around the country to talk to people who knew his father {Founder of AHRQ} and sharing the film - a lot of people share the sentiment and passion he had still inspires them today - it is really cool as his son to hear that 17 years after passed away that he still has an impact on the health care system 1:11:00 Mike feels that a lot of the work that his father did - you can see clips of him on Youtube addressing Congress - is gone - don't why - was it because of his leadership, or because it was the right time? Mike thinks we need another leader who has the ability to bring people together - the way culture is set up, we need a celebrity - Dennis Quaid, famous actor, almost had his 2 sons die due to medical error and he made a short documentary and started a foundation 1:12:30 There are other examples, Serena Williams who nearly died due to preventable harm and racism - problem is 'medical error' is a very scary term and it is applied to all doctors, nurses, surgeons and it shouldn't be that way - there is resistance by the health care industry to embrace the terms 'patient safety' etc and not as an offensive term 1:14:00 Mike is proud of father's legacy, but worries that it has been forgotten by the people who spearheaded it in the first place - we need a superhero who can jump up and say these are issues we should be talking about 1:15:00 Mike is now balancing promoting To Err is Human and speaking at medical conferences and symposiums and screened the film hundreds of times - we need to go one person at a time, change one mind at a time 1:17:00 There will be a screening of the film in Ottawa on World Patient Safety Day {Sept 17th} and for the first time there will a free online screening of the movie - to find link for free online screening check out his website ToErrIsHumanFilm.com and through twitter @ToErrIsHumanDoc 1:18:20 Website also lists other screenings in local areas - if you're interested in hosting a screening for your community, contact Mike - they tried to make the film so it is a conversation starter - but this issue is not solved, so we need to remind people where we are at, so we can continue in the right direction   Connect with Mike   Twitter: To Err is Human @ToErrIsHumanDoc   Facebook: https://www.facebook.com/ToErrIsHumanDoc   Documentary Website: https://www.toerrishumanfilm.com     ______________________________________________   Podcast Host and Counsellor Scott Simpson   Do you need an experienced counsellor for your medical error trauma?   Or for living with a chronic illness?   You can book an online video counseling appointment with me at RemediesCounseling.com           

Dr. Centor discusses the contributors to diagnostic error and strategies for reducing error with Dr. Hardeep Singh of the Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine.

Discussing clinical reasoning, cognitive bias, and diagnostic error and their implications for physicians and training programs are editor-in-chief David Sklar and senior staff editor Toni Gallo (Twitter: @ AcadMedJournal) and Dan Mayer, an emergency medicine physician who has taught on diagnostic errors and medical decision-making for more than 30 years. Read more about this topic, including the articles discussed in this episode, at: https://journals.lww.com/academicmedicine/pages/default.aspx.

Jeffrey S. Klein, MD, Editor of RadioGraphics, discusses 6 articles from the October Monograph 2018 issue of RadioGraphics. ARTICLES DISCUSSED: Esssential Role of a Medical Physicist in the Radiology Department., RadioGraphics 2018; 38:1665-1671; Lessons on Leadership., RadioGraphics 2018; 38:1688-1693; Contemporary Risk Management for Radiologists, RadioGraphics 2018; 38:1717-1728; Optimizing Performance by Preventing Disruptive Behavior in Radiology, RadioGraphics 2018; 38:1639-1650; The Late-Career Radiologist: Options and Opportunities, RadioGraphics 2018; 38:1617–1625; Fundamentals of Diagnostic Error in Imaging, RadioGraphics 2018; 38:1845-1865.

About 70 children die of sepsis per year in Australia and New Zealand. It is therefore important to have systems in place for early detection of severe infection. Developing an approach to avoid diagnostic error is an important task for each GP. In this episode, we hear from an RVTS Medical Educator, Taras Mikulin, who looks at a General Practice risk management system for use in Childhood Sepsis. Taras discusses a practical  6 step system approach to avoiding diagnostic error.

Diagnostic errors in medicine continue to be a large problem for effective healthcare delivery.  As a result, moderate and severe consequences from the errors, including death, account for 75% of diagnostic errors in the United States.  “Interventions That Can Help Reduce Diagnostic Errors” was published in the July 2018 issue of The Journal of Applied Laboratory Medicine.  The editorial discusses the associated JALM Review “The Definition and Scope of Diagnostic Error in the US and How Diagnostic Error is Enabled” by Dr. Michael Laposata. The authors of the editorial are Dr. Michael Astion and Dr. Jane Dickerson.

Another enjoyable Diagnostic Error in Medicine conference, this time in Art's home town of Boston (actually, Newton...).  In this episode we discuss our thoughts inspired by one of the sessions, run by Doug Salvador and Harry Hoar from Baystate Medical Centre. They addressed how to get one's own hospital administration to engage in Diagnostic Error.  Remember to check the website IMreasoning.com for the attachment so you can follow along while you listen.

Enjoy a short episode where we bring you our highlights of the DEM2016 conference in Hollywood, Los Angeles. This is a very well-organised, relevant, and creative conference, and it just gets better every year.  Consider attending the next DEM conference.  Either in Boston in one year, or come to visit our neck of woods for the first Australasian DEM in Melbourne in May! You can get more information on the SIDM website: http://www.improvediagnosis.org  

The Diagnostic Error in Medicine Conference 2015 has finally come!  We have been looking forward to attending this conference for a while now.  This comes on the heels of the freshly published Institute of Medicine Report on diagnostic error, an initiative which was prompted by SIDM, with Mark Graber at the helm.  These three episodes, 6, 7, and 8 are our end-of-day reflections on the presentations we have heard. Don't forget to post your comments on our website imreasoning.com, in particular about your thoughts on the IOM's definition of a diagnostic error.

The Diagnostic Error in Medicine Conference 2015 has finally come!  We have been looking forward to attending this conference for a while now.  This comes on the heels of the freshly published Institute of Medicine Report on diagnostic error, an initiative which was prompted by SIDM, with Mark Graber at the helm.  These three episodes, 6, 7, and 8 are our end-of-day reflections on the presentations we have heard. Don't forget to post your comments on our website imreasoning.com, in particular about your thoughts on the IOM's definition of a diagnostic error.

The Diagnostic Error in Medicine Conference 2015 has finally come!  We have been looking forward to attending this conference for a while now.  This comes on the heels of the freshly published Institute of Medicine Report on diagnostic error, an initiative which was prompted by SIDM, with Mark Graber at the helm.  These three episodes, 6, 7, and 8 are our end-of-day reflections on the presentations we have heard. Don't forget to post your comments on our website imreasoning.com, in particular about your thoughts on the IOM's definition of a diagnostic error.

In this episode: Jon and his KeyLIME co-hosts debate the two systems for reducing diagnostic errors in med students. Length: 16:12 min Authors: Coderre S, Wright B, McLaughlin K.  Publication details: To Think Is Good: Querying an Initial Hypothesis Reduces Diagnostic Error in Medical Students.  Academic Medicine, Vol.85, No.7/July 2010 PubMed Link View the abstract here Follow our co-hosts on Twitter! Jason R. Frank: @drjfrank  Jonathan Sherbino: @sherbino  Linda Snell: @LindaSMedEd  Want to learn more about KeyLIME? Click here!

A female patient wasn't screened for colon cancer, despite routine involvement with three physicians.