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