Reducing Diagnostic Error Tim Shoen, MD Campaign for Quality October 17, 2014.

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Reducing Diagnostic Error Tim Shoen, MD Campaign for Quality October 17, 2014

Transcript of Reducing Diagnostic Error Tim Shoen, MD Campaign for Quality October 17, 2014.

Page 1: Reducing Diagnostic Error Tim Shoen, MD Campaign for Quality October 17, 2014.

Reducing Diagnostic Error

Tim Shoen, MD

Campaign for Quality

October 17, 2014

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Disclosure

No financial interest to disclose

Thanks to Mark Graber, MD, President, SIDM.

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Sue Sheridan

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Wall Street Journal

The Biggest Mistake Doctors Make

Misdiagnoses are Harmful and Costly

But they're often preventable

Laura Landro

November 17, 2013

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Patient Safety Awareness 2014

Creating a world where patients and those that care for them are free from harm.

www.npsf.org

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Society to Improve Diagnosis in Medicine

We envision a world where diagnosis is accurate, timely, and efficient.

www.improvediagnosis.org

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Gregory House, MD

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Objectives

• Review Incidence

• Contribution of Cognitive and System factors

• Improvement Efforts

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Diagnosis

The satisfaction of solving The Riddle…is every doctor’s measure of his own abilities; it is the most important ingredient in his professional self-image.

Dr. Sherwin Nuland

How We Die 1994

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Human Error

• Skill Based – error rate 1:1000

• Rule Based– error rate 1:100

• Knowledge Based– error rate 1:2

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Preventable Harm

ErrorAdvers

e

Event

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Diagnostic Error

• Delayed Diagnosis

• Missed Diagnosis

• Wrong Diagnosis

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Expert A. Elstein: 10-15%

Patient Survey

One third relate a Dx error affected themselves, family

SecondReviews

Radiology and Pathology: 2-5% cancers missed

Look backs 30% of subarachnoid hemorrhage misdiagnosed; 39% of dissecting AAA delayed diagnosis; A third of neurological diagnoses wrong or likely wrong

Autopsy Major unexpected discrepancies that would have changed the management are found in 10-20%

Estimates of Dx Error Rate

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Estimates Diagnostic Error Rate

Trauma 8% of pts have missed injuries

General ER .6% of 5000 admitted pts at Wayne State

MI 2-3% of pts sent home have an MI; 90% of pts admitted don’t have an MI or ACS

Liability 47% claims high severity cases alleged Dx related

OutpatientClinic

1:20 patients experience dx error each year

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Diagnostic Errors

• Are common and cause enormous harm

• Estimates 40,000-80,000 annual deaths

• Overlooked with emphasis on system improvement

• Measurement tools lacking

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Etiology of Diagnostic Error

Both System and Cognitive Errors

46%

Cognitive Error Only28%

System Error Only19%

No Fault Error Only7%

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Cognitive Errors: 320

Faulty Synthesis 83 %

Faulty Knowledge

3 %

Faulty Data Gathering 14 %

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Diagnostic Errors

• Are common and cause enormous harm

• Most errors involve both system and cognitive components.

• Cognitive errors most often reflect problems using intuition

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Cognitive Psychology

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Brain

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Hard wiringAmbient conditions/ContextTask characteristicsAge and ExperienceAffective stateGenderPersonality

EducationTrainingCritical thinkingLogical competenceRationalityFeedbackIntellectual ability

Pattern Recognition

Repetition

Executiveoverride

Dysrationaliaoverride Calibration Diagnosis

PatientPresentation

PatternProcessor

RECOGNIZED

NOTRECOGNIZED

1

2

Dual Process Model of Clinical Reasoning

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Heuristic and Bias

• Confirmation Bias

• Availability

• Anchoring

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COGNITIVE ERRORS Most common:

• Premature closure (39)• Faulty context generation (26)• Faulty perception (25)• Failed heuristic (23)

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Problems Solutions

• Faulty context• Premature closure• Failed heuristic• Framing errors

• Consider the opposite• Crystal ball experience• Reflection• Be comprehensive• Learn the antidotes

How can we make diagnosis more reliable ?

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DX Reasoning

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The PROBLEM: COMPLEXITY

The SOLUTION:NOT training; NOT redesign

A Checklist

The B-17, and its checklist, flew the next 1.8 million miles without an accident. The military obtained over 13,000, and the B-17 was the workhorse of the Allied air force in

World War II.

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13,000 known diseases, syndromes, injuries

4,000 possible tests

6,000 medications, treatments, and surgeries

The average limits of human working memory:7 discrete items

Complexity in Medicine

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The Surgical Checklist• WHO sponsored study in 8 countries• 19 item checklist:

– Sign in + Time out + sign out• Evaluated in 3733 operations:• Results:

– Major complications fell from 11 to 7%– Death rate fell from 1.5 to 0.7% (p = 0.003)

Haynes et al. NEJM 360: 491-9, 2009

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A Checklist for Diagnosis

Obtain YOUR OWN history Perform a focused, purposeful exam Take a “Diagnostic Time Out”

Was I comprehensive ? Did I consider the inherent shortcomings of using my

intuition (heuristics) ? Was my judgment affected by bias ? Do I need to make the diagnosis now or can it wait ? What’s the worst case scenario?

Embark on the plan, but ENSURE FOLLOW-UP & FEEDBACK

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Structured ReflectionV ascularI nfections & intoxicationsT rauma & toxinsA uto-immuneM etabolicI diopathic & iatrogenicN eoplasticC ongenitalC onversion (psychiatric)D egenerativeE ndocrine

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Possible Solutions

• National Agenda

• Research

• Health IT

• Clinical Reasoning Education

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Summary

• Diagnosis errors are common and harmful

• High quality healthcare requires high quality diagnosis

• Diagnostic errors are costly• Healthcare Organizations are well

positioned to lead efforts to reducing these errors

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Case Studies

• Maine Medical Center– Physician Reporting

• SoCal Kaiser Permanente– Electronic Records to Trace Diagnostic

Error

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Reference

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Reference

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Questions?

Tim Shoen, MD

[email protected]

Subject: Dx Error