Thanks for the details. (01)
I guess your point can be made with this tale, certainly given an occurrence
30 years ago, but in my experience, this type of thing just does not happen
in medicine in this day and age (last 20 years). (02)
Doctors scripts are double checked by first the pharmacy staff and secondly
by the nurse administering the medication. Most medical errors have nothing
to do with logic but more with carelessness (nurse give the medication to
the wrong patient accidentally, the meds are given too late which pushes
them close to a next dose, administered by another nurse that comes on the
next shift, a doctor operates on the wrong limb because he did not check the
chart again). (03)
This is why I think that the IOM report on 90,000 deaths from medical errors
that led to everyone throwing money at decision support systems and 200
million dollar software systems to address the issue is off target in my
opinion. (04)
Most errors in hospitalized patients (in my personal experience) are due to
lack of adequate staffing of nurses on the floor to care for the patients.
So a urinary catheter that was supposed to be pulled 12 hours after surgery
sits for 30 hours and the patient gets a urinary tract infection that seeds
bacterial sepsis. I don't see an error in logic here, because everyone knew
it was supposed to come out, knew the consequences, but no one got around to
doing it due to staffing and treating more critical patients (or demanding
in some way) first. I don't even know if an alarm bell triggered by software
would help, because they may use logic to continue suctioning the trachea of
the person with pneumonia because it takes life/death priority. (05)
It seems to me that the error in logic might be that at times we don't look
at the error logically. (06)
Cecil
-----Original Message-----
From: Kathryn Blackmond Laskey [mailto:klaskey@xxxxxxx]
Sent: Saturday, August 11, 2007 8:36 AM
To: clynch@xxxxxxxxxxxxxx; 'Kathryn Blackmond Laskey'; '[ontolog-forum] ';
'Azamat'
Subject: RE: [ontolog-forum] Reality Oriented Logic (07)
The error in dosage happened to my college boyfriend's mother's
boyfriend's father. (Got that?) It happened at least 30 years ago.
I never met the fellow, but the story was a favorite topic of
conversation in my boyfriend's family. My recollection was that it
was an error in logic. I won't swear by the details, both because I
got them secondhand and because I've not had any contact with the
boyfriend or his family for a couple of decades. (08)
But does it really matter what the details are of this particular
story? I intended it as an illustration that logic can be used to
reason about the real world, and when logic is used to reason about
the real world, there can be life-and-death consequences to getting
the logic right. My point would have been just as valid if I had
said, "Suppose a physician makes an error in logic when calculating
the dosage of medication. Someone could die as a result." (09)
K (010)
At 9:35 PM -0700 8/10/07, clynch wrote:
>I assume that you knew of the details of the case personally since, from
>your description, I could not assume that there was an error in logic. It
>could have been a visual problem with the physician writing the script, a
>pharmacist reading it, or even a message error if it were an NCPDP HL7
>message with an erroneous Units of Measure entry.
>
>Thanks
>Cecil
>
>-----Original Message-----
>From: Kathryn Blackmond Laskey [mailto:klaskey@xxxxxxx]
>Sent: Friday, August 10, 2007 3:19 PM
>To: clynch@xxxxxxxxxxxxxx; [ontolog-forum] ; 'Azamat'
>Subject: Re: [ontolog-forum] Reality Oriented Logic
>
>Miscalculating the location of the decimal point.
>
>At 2:32 PM -0700 8/10/07, clynch wrote:
>>Hi Kathy,
>>
>>What specifically was the "error in logic"?
>>
>>Cecil Lynch
>>
>>-----Original Message-----
>>From: ontolog-forum-bounces@xxxxxxxxxxxxxxxx
>>[mailto:ontolog-forum-bounces@xxxxxxxxxxxxxxxx] On Behalf Of Kathryn
>>Blackmond Laskey
>>Sent: Friday, August 10, 2007 1:00 PM
>>To: [ontolog-forum] ; Azamat
>>Cc: [ontolog-forum]
>>Subject: Re: [ontolog-forum] Reality Oriented Logic
>>
>>>...Ontology deals with the matter and content, with the real components
of
>>> >discourse about anything, while Logic is an art, an instrument of
>>>>intellectual reasoning, at least a formal science
>>>
>>>Even let us agree (temporarily) to this ...
>>>
>>>>,and it has nothing to do
>>>>with reality, real significance or real meanings,
>>>
>>> ... but this is a mistake, a non-sequiteur.
>>
>>I once knew someone who was disabled for life because a medical
>>professional missed a decimal point and gave him an order of
>>magnitude higher dose of a drug than he should have had. The medical
>>professional's career was ruined. The insurance company was out more
>>than a million dollars. The patient's life was radically transformed
>>for the worse.
>>
>>All due to an error in logic.
>>
>>This had *very much* to do with reality It had very real
>>significance, and very real meaning.
>>
>>Kathy
>>
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