Error: ¿Why? ERROR System -Work place -Communicatión -Alerts
System and Diagnosis An 35 y/o man went to ED Referring back pain and paraparesia He went twice to the ED. No one asked.. And couldn,t retrieve medical record At that moment was impossible to track a diagnosis of melanoma two years before Doctor´s mind: a young Person can,t have An important disease SYSTEM Cognitive
JAMA Volume 301(10) March 11, 2009 Copyright 2009 by the American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use. American Medical Association, 515 N. State St, Chicago, IL 60610. ISSN: 0098-7484
A patient with a diagnosis of CPOD started with pain and shock during the night. The Hemoglobin levels were around 14. No one thought about bleeding: but he was polycitemic and his previous Hemoglobin levels were over 18..
An old man went to the ED after a fall. At the hand recors some doctor wrote: right arm thrombosis
Next day the right arm was paretic.
Pancoast tumor : 5% lung cancer Horner Syndrom: 14-50% of cases. Framing : old people felt down .. Because they felt down Premature closing : no one examine the information about the previous diagnosis.
Fish bone diagram to study the systems aspects related to diagnosis FAILURE TEAM Communicatión Coordinatión Training PROCESS Not specified Lack of material No supervisión Bad asignament Wrong test ROLES Wrong evaluation of urgency Complications No alerts Inefficient summary of data COGNITIVE COMPOUND