Elizabeth Nilson, MD
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Nilson E.; Bad Outcomes of Questionable Medical Decisions. Ann Intern Med. 2003;138:519-520. doi: 10.7326/0003-4819-138-6-200303180-00027
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Published: Ann Intern Med. 2003;138(6):519-520.
TO THE EDITOR:
Drs. Hofer and Hayward make a cogent argument against performing a lengthy root-cause analysis when there is probably no identifiable “systems problem” that resulted in a bad outcome (1). As they discuss, the bad outcome is probably the result of a series of risky medical procedures and decisions. However, such cases are worthy of analysis for performance improvement—something that is intimately tied to peer review, quality assurance, and patient safety, as well as mandated by regulatory agencies.
The case described by Hofer and Hayward is in itself compelling. An evidence-based medicine discussion about diagnostic tests and their limitations, predictive values, and role in clinical decision making might affect a future decision about whether to order a ventilation-perfusion scan or spiral computed tomography to diagnose a pulmonary embolus and thus prevent a future problem. Investigating how anticoagulation is ordered or how residents sign out patients might reveal a remediable “systems” problem and help avoid delayed procedures because of inadvertently prolonged anticoagulation in future patients. While a true root-cause analysis is lengthy and labor intensive and ultimately is not guaranteed to improve outcomes, the essence of the process—reviewing a series of tasks to identify potential pitfalls—is valuable.
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Print ISSN: 0003-4819 | Online ISSN: 1539-3704
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