Improving Diagnosis

• Cognitive bias

• Dr.Lorenzo Alonso

• Foro Osler: www.foro-osler.com

Adverse events: 3,7% : 14% deaths

27% malpractice: 75% diagnostic problem.

Most common medical errors

Error: ¿Why?

ERROR

System

-Work place

-Communicatión

-Alerts

Individual

-fatigue, strees,..

- reasoning

- experience

- metacognition

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 importantdisease

SYSTEM

Cognitive

JAMAVolume 301(10)

March 11, 2009Copyright 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

Diagnostic errors: Definition

• Diagnostic never made.

• Wrong Diagnostic.

• Late Diagnostic.

Diagnostic error compound

More automatic:

More experience

More analysis

Slower

Less experience

Wrong mentalreasoning

Lack ofInformation.Rethinking

Two Systems of reasoning (Croskerry)

Examples of Cognitive errors (heuristics)

Next cartoons extracted from: Sox. Clinical Decision Making. Butterworth-Heineman 1988.

Representation heuristics

Endocrinologist think

About Cushing in a patient with high BP and hirsutism (non prevalent)

Availability

The intern saw two

Splenic abscess in the previous rotation. Now he thinks that there is another one in front

Of him.

Premature closing

I don,t have the biopsy but anyway, he just came

with fever.

Overconfidence

Framing: to put labels on people

Case 1

• 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..

Retroperitoneal Hematoma

Hb

13/5/08

19

18/05

17,5

19/05

16,5

21/05

15

22/05/10

14,5

System Failure:”:Communicatión

Organizatión informatión

Case 2

• 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.

Recipe to improve diagnostic abilities

• Common sense

• Method

• Study

• Teamwork

• Metacognition: to know how we think.

Fish bone diagram to study the systems aspects related to diagnosis

FAILURETEAM

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

(Checklist)

Dr. M. Graber

IMPROVEMENT AND CHANGE IS POSSIBLE