diagnostic error in medicine 1st european conference june ... error in medicine... · yoryos...

DOI 10.1515/dx-2016-0015 Diagnosis 2016; 3(2): eA1–eA36

Abstracts*)

Diagnostic Error in Medicine 1st European Conference June 30–July 1, 2016

Organizing and Scientific CommitteeLaura Zwaan, PhD (chair)

Yoryos (Georgios) Lyratzopoulos, MD, FFPH, FRCP, MPH (co-chair)Jason Maude

Maarten ten Berg, PhD

Abstract CommitteeKaren Stegers-Jager, PhDSílvia Mamede, MD, PhD

*)These abstracts have been reproduced directly from the material supplied by the authors, without editorial alteration by the staff of this Journal. Insufficiencies of preparation, grammar, spelling, style, syntax and usage are the authors’ responsibility.

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eA2 Diagnostic Error in Medicine: 1st European Conference. Rotterdam, Netherlands, 30 June–1 July 2016

Abstracts selected for an oral presentation June 30, 17.15-18.15h


Diagnostic Error in Medicine: 1st European Conference. Rotterdam, Netherlands, 30 June–1 July 2016 eA3

How common are diagnostic failures? Indications from national Swedish registries.Anders von Heijne MD1

1Department of Radiology, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden

Background: Diagnostic failures are common in health care, but difficult to measure. In Sweden, where private healthcare is uncommon, and national registries are well developed, national databases shed some light on the incidence of diagnostic failures.Methods: Publicly reported data, previously not compiled, were accessed from four partially overlapping sources and compared with the few scientific studies performed in Sweden in this field.

– Adverse events (2014 and 2015) reported to The Health and Social Care Inspectorate (IVO) under the Patient Safety Act of 2010. – Patient complaints (2014) to Patient Advisory Committees in all counties and regions. – Insurance claims (2000-2014) to LÖF (mutual insurance company owned by its policy holders, the Swedish counties and regions) under

the Patient Injury Act of 1996. – National IT-support system for root cause analyses (NITHA) – cases with adverse events and/or patient harm analysed using this tool can

be saved in an anonymised database.Results:

– Diagnostic failures were the cause of 21% of adverse events reported to IVO in 2014 and 2015. Reporting of severe patient injury is manda-tory for caregivers and in these cases diagnostic failures were the cause in 19.3 % (2015) but more common in Emergency departments (50%), General practice (40%) and Radiology (75%), perhaps unsurprising in specialties with significant diagnostic uncertainty or that are predominantly diagnostic.

– 28% of health care related patient complaints to the PAC’s were about the diagnostic process or the diagnosis. – 1000-1100 claims due to diagnosis-related patient injury are filed annually at LÖF, with stable numbers from 2000, comprising 8 - 12 %

of the total number of claims. – In NITHA 22.6 % of cases has diagnosis as root cause for the adverse event.

Conclusion: Diagnostic failures are common as indicated in publicly available data, and replicates findings from research. Improved clas-sification of cases in national registries, as well as correlation to national quality registries, might lead to better and more detailed aggregated knowledge and improved feedback to the health care system.References:Contributing factors to errors in Swedish emergency departments. Källberg AS et al. Int Emerg Nurs. 2015 Apr;23(2):156-61.The incidence of adverse events in Swedish hospitals: a retrospective medical record review study. Soop M et al. Int J Qual Health Care. 2009 Aug;21(4):285-91

Teaching search strategies to avoid errors in radiology

Anouk van der Gijp1, K.L. Vincken1, C. Boscardin2, E. M. Webb2, Th.J. ten Cate1, D. M. Naeger2

1University Medical Center Utrecht, The Netherlands2University of California San Francisco, USA

Background: Perceptual errors in radiology may be due to inefficient search strategies. Especially with the growing amount of image data of multislice CT scans, an efficient approach to image data is needed to avoid missing lesions. For example, ‘scanning’ and ‘drilling’, are two search strategies that are used by expert radiologists, and show different error rates. Teaching trainees to use efficient search strategies could potentially avoid perceptual errors. However, it is not known if expert search strategies can be taught to junior trainees. Besides, using expert search strategies may not decrease the number of errors in novice learners who lack the knowledge and experience of experts. We therefore investigated if expert search strategies can be taught to junior trainees and if it could improve their perceptual accuracy.Methods: We investigated perceptual performance of a lung nodule detection task in CT scans. The two expert search strategies, ‘drilling’ and ‘scanning’, were compared in a randomized cross over design. A drilling strategy means looking at small regions within an image while scrolling up and down, while scanning involves scrutinizing each image completely, one by one. Nineteen first and second year radi-ology residents were randomly divided in two groups. Both groups first took a lung nodule detection pretest using a free search strategy. Second, they completed a similar test after scanning instruction and drilling instruction or vice versa. We registered scroll behavior and true and false positive scores. Scroll behavior and perceptual performance in the three search conditions were compared using a mixed design ANOVA.Results: We found a significant effect of search strategy instruction on scroll behavior, F (1.3) = 54.2, p < 0.001, true positive score, F (2) = 16.1, p < 0.001, and false positive score, F (1.3) = 15.3, p < 0.001. There were no significant interaction effects on scroll behavior and perceptual performance. Drilling led to significantly higher true positive scores than scanning (M 16.3, SD 5.3 versus M 10.7, SD 5.0); t(18) = 4.78, p < 0.001, though did not significantly improve detection compared to free search. Drilling resulted in a significantly lower false positive score than free search (M 7.3, SD 5.6 versus M 12.5, SD 7.8); t(18) = 4.86, p < 0.001.Conclusion: Teaching search strategies can affect search behavior and perceptual accuracy of junior trainees. To avoid perceptual errors, teaching a drilling strategy is preferable over teaching a scanning strategy.



The adaption, implementation and evaluation of collaborative service improvements in the testing and result communication process in Primary Care: Patient and staff perspectives

Ian Litchfield1, Louise Bentham2, Ann Hill3, Richard McManus4, Richard Lilford5, Sheila Greenfield6

1Health and Population Sciences, Institute of Occupational and Environmental Medicine, Birmingham, United Kingdom2Health and Population Sciences, University of Birmingham, Birmingham, UK3Worcestershire Acute Hospitals NHS Trust, Worcester, UK4Primary Care Health Sciences, University of Oxford, Oxford, UK5Health Sciences, University of Warwick, Coventry, UK6Primary Care Clinical Sciences, University of Birmingham, Birmingham, UK

Background: In the UK, the Test Result Communication Knowledge, Evaluation and Development (TRaCKED) study used the principles of “Experience-based Co-design” (The King’s Fund. Experience-based co-design toolkit. 2014) to work with patients and staff to improve the testing and result communication process for blood test results clinical investigations in primary care. In doing so we identified six key areas of weakness in the existing process that ranged from delay in accessing phlebotomy to the lack of patient awareness of how to retrieve results (Litchfield et al 2015). A number of ideas for improvement were sourced from patients and staff that attempted to reconcile the preferences of both groups with the available resources and aiming to refine, implemented and evaluate these proposals (Litchfield et al 2014; Litchfield et al 2015). Here we report on which issues should be dealt with and how, and summarise the post-implementation evaluation of these interven-tions from the perspectives of both staff and patients.Methods: The TRaCKED study consisted of four phases (see figure 1). Here we report on Phases 3 and 4 where we worked closely with two practices to select and refine potential solutions to the areas of weakness in their existing systems. These are described in Table 1. We then conducted focus groups at each practice for a preliminary evaluation of their acceptability and effectiveness.Results: Despite the use of a collaborative improvement methodology intended to facilitate consensual and applicable improvement strate-gies, not every suggestion sourced was adopted as prescribed (see Table 1) and in some cases original solutions emerged. The changes effected were well received by both patients and staff including increased access to phlebotomy.

“Yeah, we’ve had quite an increase in phlebotomy [capacity] ‘cause at one stage we were up to two plus weeks’ wait… now the access to phlebotomy is better, [the nurses] can be freed up to do what they’re meant to do – which isn’t taking blood.” GP1 (male) Practice 1

More support for receptionists relaying results…

“Phoned the receptionist; good as gold. ‘Sorry, you’ve got one result back which is fine, the rest of your results aren’t back yet. Can you ring again between 3 and 4?’” Patient 1 (male) Practice 1

…and the use of an information leaflet describing the tests ordered and the means of collecting results.

“It’s great for patients and you can also show them the important things, like whether to phone for results and the number of tests ordered…I think what we all wanted to avoid is this problem, which happens not infrequently, where people ring up and are told “every-thing is normal”, when in fact not everything is back, and this is the real danger, isn’t it?” GP2 (female) Practice 1”.

Conclusion: Though not all of the suggested improvements were adopted the engagement of practice staff, encouraged by their growing awareness of the problem, meant a significant number of changes to existing systems were usefully implemented. The different ways in which each practice tackled the same issue were influenced by a number of factors including the attitudes of individual staff members, and characteristics of the organisation and its patients. We understand that not every solution we identified or was implemented is appli-cable to every practice, yet at the very least this study has helped raise awareness of weaknesses in one of the core functions of primary care.



Patient focusgroups

A minimum ofone per practiceconsisting solely

of patientsfrom thatpractice

Staff focusgroups

One per practiceconsisting solely

of staff fromthat practice

Telephonesurvey

Conducted withsenior

administrativestaff at 50

practices acrossthe UK

Iterative meetings with practice staffto determine which of six key recommendations will be

introduced and how they will be implemented.

Phase 1: Assessment of strengths and weakness of currentand preferred methods of communication

Collation of ideas for improving current systems

Phase 2: Development of ideas for improvements intopractical solutions for implementation

2 x Focus groups of mixed groups of staff and patientsfrom across the four study practices

Phase 3: Refinement of proposed solutions for implementation

Phase 4: Implementation and Evaluation

Laboratoryperspective

Iterativeinterviews withlaboratory staff

Patient focus groupsA minimum of one per

practice consistingsolely of patientsfrom that practice

Staff focus groupsOne per practice

consisting solely ofstaff from that

practice

Final report

Figure 1: The four phase design of the TRaCKED Study

Appendix 1

Table 1: Suggested solutions and those adopted by each practice

Issue

Proposed solutions

Solution implemented (in bold)

Practice 1 and 2 Practice 1 Practice 2

Delay in access to phlebotomy

1) Reconfigure appointments to meet demand.

2) Increase the hours of phlebotomists.3) Train existing staff in phlebotomy to

provide support for phlebotomists.

Employed additional HCAExtended clinic to the afternoon

Trained existing staff in phlebotomy.Kept additional appointments free

Lack of an alert for delayed or missing results

Alerts embedded in the clinical management system issued if:1) The result has not been returned by

the laboratory2) The result has not been seen by GPs3) The result has reached patients

The technical development needed could not be achieved within the time scale.

Would not commit to improving existing system with laboratory services out for tender

Delays for patients seeking results via telephone

1) Precise time slot for calling for results2) Separate phone line for results3) Call waiting

Patient demographic deemed unsuitable.

New telephone system recently procured.



Issue

Proposed solutions

Solution implemented (in bold)

Practice 1 and 2 Practice 1 Practice 2

Receptionists reporting clinical information

1) Support data protection act compliance by receptionists

2) Training for receptionists in how to communicate potentially sensitive information

3) Improving access to teleconsultations with GPs

4) Greater clarity in the script provided by GPs

The importance of the accurate communication of result information was raised with reception staff.

Receptionists instructed to advise patients that there may be results outstanding.The number of teleconsultations with GPs was increased.

Lack of routine communication of results

1) via SMS2) via letter3) via email

Selective use of SMS. Selective use of SMS.Letters routinely sent to patients with abnormal results advising them to book/keep their appointment.

Lack of patient awareness of the communication pathway

1) Poster on wall in waiting room2) Information leaflet for patients

detailing tests ordered and the means of retrieving their results embedded within clinical management system.

Information leaflet for patients printed and distributed by GPs.

Issues with software provider meant it could not be achieved within the timescale of the study.

Table 1 (continued)

High-risk patient monitoring in ambulatory settings: applying journey mapping to identify leverage points to reduce diagnostic delays and increase organizational effectiveness

Kathryn McDonald1, George Su2, Sarah Lisker2, Emily Patterson3, Urmimala Sarkar2

1Stanford University, University of California Berkeley2University of California San Francisco3Ohio State University

Background: Missed monitoring in high-risk conditions leads to diagnostic delays, but current mitigating solutions are inadequate. In response, our Ambulatory Safety Center for Innovation (ASCENT) learning laboratory aims to characterize existing methods for monitoring of high-risk conditions within an urban publicly funded health system, identify common vulnerabilities, and develop key attributes for interven-tions. This qualitative research will inform prototyping, piloting and full-scale testing of technical and organizational interventions, with the aim of producing robust population-level monitoring solutions for widespread implementation.Methods: We conducted semi-structured interviews with staff in otolaryngology, pulmonary medicine, urology, breast cancer center, and gas-troenterology. During these interviews, we applied a human factors technique called journey mapping to co-create a visual representation of how patients are monitored for high-risk conditions in each specialty clinic. The research team analyzed interview notes and journey maps to identify common systems vulnerabilities and seeds to design solutions for more robust monitoring of high-risk conditions over time (“design seeds”). Finally, we conducted a face validity and prioritization assessment of the design seeds with the original interviewees.Results: We identified 5 high-risk situations for potentially consequential diagnostic delays arising from not monitoring a patient as planned, and related to detection of lung cancer, colorectal cancer, breast cancer, head and neck cancer, or prostate cancer. With the clinic informants, we created 5 journey maps, each representing specialty clinic workflow directed at appropriate monitoring. System vulnerabilities common to the different clinics included troubles with: data systems, communications handoffs, population-level tracking, patient contacting, and patient showing up. Examples of the 13 design seeds addressing these vulnerabilities include: Create a functional list of patients for popula-tion management, identify scheduling-related challenges, and provide performance data. Each design seed has specific evaluation criteria for potential solutions developed from the seed and poised to guide development of a valid and valuable design solution.Conclusion: These conditions exemplify challenging high-risk situations for appropriate follow-up care to prevent harm in ambulatory set-tings. We anticipate that the design seeds resulting from this study will grow into more robust solutions to these diagnostic safety targets than



solutions generated by a traditional approach because they provide a human-centered link between the experienced problem and various solutions that can be tested for viability and sustainability. Physicians agreed that these situations “wake them up at night,” and that the design seeds offer an important opportunity to reduce their worry, save time, and improve diagnostic safety.

Diagnostic failure: A medical malpractice claims review

A. Anderson, K. Berquist, J. Hoffman, M. Janes, G. Ruoff, D. Siegal, B. Szeidler

Background: To understand common vulnerabilities driving medical malpractice claims in the United States, CRICO, the Medical Malpractice insurer of the Harvard Medical Institutions maintains a national database of > 350,000 medical malpractice claims from academic and com-munity organization across the country. Analysis of this data provides detailed insights of common causation patterns and trends that drive medical error and harm in all case types including diagnostic failure.Methods: Using CRICO’s clinical coding taxonomy, coding specialists review medical and legal files for each claim. This multi-tiered tax-onomy allows coders to capture key elements of each case (e.g. allegation, responsible service, diagnoses, comorbidities, procedures, medi-cation, etc.), assign associated causation factors (e.g. clinical judgment, communication, technical, behavioral etc.) and provide an event summary documenting the rational for each causation factor.Results: Analysis of 22,292 medical malpractice claims filed 2008-2012 found 21% were linked to diagnostic error. Of the 4,519 diagnosis related cases, 51% (2,531 cases) occurred in ambulatory care, 28% (1,253) inpatient and 16% were ED care.General Medicine accounted for nearly 50% of the ambulatory cases; Surgery 17% (Orthopedics and General); Radiology 14%. Cancer and cardiac events led the list of missed diagnoses - 60% resulted in serious harm or death. Medicine (Internal, Hospitalist, Cardiology, Neurology) was most named in inpatient diagnostic related cases (45%); Surgery accounted for 23%. Main allegations were cardiac events and missed complications of care; 73% resulted in server harm or death. Cardiac, Neurology, and GI events topped the ED list.Clinical judgment factors were found in nearly 75% of all cases e.g. narrow diagnostic focus and failure to order an inpatient consult (17%) or ambulatory referral (19%). Gaps in communication between providers was more prevalent in the inpatient setting (20% vs. 10% in ambula-tory) while failure to order tests (31%) was a key driver of ambulatory claims. Misinterpretation of diagnostic studies drove both inpatient (15%) and ambulatory (21%) cases.Conclusion: Analysis of medical malpractice cases offers a unique lens into the most egregious of diagnostic failures. By studying these cases we gain insight into specific patterns of care that may be amenable to improvement opportunities. Based on these data, CRICO/Harvard has prioritized several patient safety efforts focused on specific diagnostic issues in the ambulatory setting (51% of cases) including efforts focus on improved communication between providers (including the ED), test ordering and referral management. The data is a critical tool for engaging providers in these issues.

Diagnostic feedback: learning from diagnostic error in clinical practice during residency training.

R. van den Broek, M.D., resident internal medicine, M.O. van Aken, M.D., PhD., internist-endocrinologistDepartment of Internal Medicine, HagaHospital, the Hague, the Netherlands

Statement of problem: Learning from diagnostic error during medical training is currently not an integral part of most residency training programs. Especially, diagnostic errors made during night- and weekend shifts often remain unnoticed by the physician who made the initial diagnosis, due to fragmented duty-rosters and lack of structured feedback.Description of the intervention or program: Diagnostic feedback was introduced in our residency training program. From all patients admitted to the department of internal medicine during weekend shifts (Friday evening till Monday morning), intake-diagnosis and discharge diagnosis are recorded in a database. All residents and supervising internists receive a list of the patients they admitted in the previous month. In those cases with different intake versus discharge diagnoses, a structured evaluation is made of the diagnostic process and the possible explanation for diagnostic error. The residents present their findings in a monthly meeting. Common heuristics related to diagnostic flaws are discussed in the context of the cases presented.Findings to date: In the implementation phase, differences between intake and discharge diagnosis were found in approximately 15% of patients. Partly, these differences are explained by narrowing down of the diagnosis at intake (for instance sepsis of unknown origin to urinary tract infection with sepsis). Evaluation of the diagnostic process revealed that premature closure, anchoring bias and availability bias were frequent causes of diagnostic error. Residents and supervising internists experienced this direct feedback on their diagnostic skills as useful. More specifically, the combination of individual feedback and the evaluation of the diagnostic process in general, were perceived as meaningful.Lessons learned: Diagnostic feedback appears to be a valuable learning tool in a residency training program. Gathering further experience with and optimization of this process is planned for the near future.



Posters presentation June 30, 17.15-18.15h Scientific abstracts



1.

Variations in GPs’ decisions to investigate suspected lung cancer: A factorial experiment using multimedia vignettes

Jessica Sheringham1, Rachel Sequeira1, Jonathan Myles2, William Hamilton3, Joe McDonnell4, Judith Offman2, Angelos Kassianos1, Stephen Duffy2, Rosalind Raine1

1Department of Applied Health Research, London UK2Centre for Cancer Prevention, Queen Mary University of London, Wolfson Institute of Preventive Medicine, London UK3University of Exeter, College House, St Luke’s Campus, Exeter UK4London Borough of Waltham Forest, Waltham Forest Town Hall, Walthamstow UK

Background: Most lung cancer patients first present to primary care but diagnostic delays are well documented: lung cancer patients have more consultations in primary care before investigation than many other cancers. Missed opportunities for lung cancer diagnosis in primary care may contribute to poor lung cancer survival. Patients with symptoms suggestive of lung cancer commonly present to primary care but it is unclear how general practitioners (GPs) distinguish which patients require further investigation. This factorial experiment examined how patients’ clinical and socio-demographic characteristics influence GPs’ decisions to initiate lung cancer investigations.Methods: A multimedia interactive website simulated key features of GP consultations using actors (‘patients’). A national sample of GPs made management decisions online for six ‘patients’ randomly selected from 36 vignettes, with clinical and socio-demographic character-istics systematically varying across three levels of cancer risk. In low-risk vignettes (positive predictive value [PPV] < 1·2%) investigation by the GP (i.e. chest X-ray ordered or respiratory physician referral) was not indicated, in medium-risk (PPV = 1·7-2·5%) investigation could be appropriate, in high-risk vignettes (PPV > 3%) investigation was definitely indicated. Each ‘patient’ had two lung cancer-related symptoms; one volunteered and the other elicited if GPs specifically requested it. Variations in investigation likelihood were examined by ‘patient’ char-acteristics using multilevel logistic regression.Results: GPs decided to investigate lung cancer in 74% (1000/1348) of vignettes. Investigation likelihood did not increase with cancer risk. Investigations were more likely when GPs requested additional information on relevant symptoms that ‘patients’ had but did not volunteer (adjusted odds ratio = 3.18; 95%CI 2.27-4.70). However GPs omitted to seek this information in 42% (570/1348) of cases. GPs were less likely to investigate older than younger ‘patients’ (adjusted odds ratio = 0.52 95%CI 0.39-0.7]) and Black ‘patients’ than White (adjusted odds ratio = 0.68; 95%CI 0.48-0.95).Conclusion: GPs’ investigation decisions were influenced by whether they actively sought sufficient clinical information and by patients’ age and ethnicity, irrespective of their clinical risk.To reduce the potential for missed opportunities for timely diagnosis of lung cancer error, strategies are needed to prompt doctors to actively seek out germane symptom information. To generate a better understanding of GPs’ reasoning processes in making decisions with older and non-White patients and reverse a lower willingness to investigate, further research to investigate and tackle cognitive biases may be required.

2.

Malpractice risk in the diagnostic process: Diagnostic vulnerabilities and patient safety in the ambulatory setting

A. Anderson, K. Berquist, J. Hoffman, M. Janes, G. Ruoff, D. Siegal, B. SzeidlerCRICO RMF

Background: To understand common vulnerabilities that lead to the claim of ambulatory diagnostic error in the United States, we reviewed 2,685 ambulatory medical open and closed malpractice cases with the allegation of missed or delayed diagnosis that led to patient harm.Methods: The nature of diagnostic errors remains a challenge and particularly in ambulatory care. Review of 23,527 medical malpractice cases filed from 2008-2012 noted that 20% of those cases linked to diagnostic error, (28% were surgical treatment, 23% were medical treatment, 7% obstetrics and 22% other). A drill into the 4,703 diagnosis related cases found that most diagnostic error, 2,685 cases occurred in ambula-tory care. Ambulatory care excludes emergency medicine cases. Based on the identification of a greater percentage of ambulatory diagnostic malpractice cases, a focused analysis was conducted. Recognizing the growing focus of diagnostic failure, the detailed review of these cases help to shine a brighter light on diagnostic vulnerabilities and potential opportunities to improve diagnostic patient safety in ambulatory care.Results: The most frequently named responsible service was medicine with 49% followed by surgery with 17%, radiology with 15% and pathology/other with 19% of the cases. The top three diagnostic failures were of cancer 45%, followed by heart disease and orthopedic injuries each occurring in 6% of the diagnostic failure cases. Case review resulted in 82% of the identified contributing factors were able to be mapped to the 12 step diagnostic process of care. The 12 steps diagnostic process of care factors were then refined to three broad phases; Initial diag-nostic assessment failures 58%, Testing and results processing 29%, and Follow up/ Coordination 46%.Conclusion: There are expansion of diagnostic capabilities that include the use of cancer screening guidelines such as breast care and colo-rectal, electronic support to assist in closing the loop of communication of diagnostic imaging and referral management systems that can track the referral process through from time of referral made through to patient made aware of results and plan. The use of the whole team in assessing potential practice vulnerabilities or in conducting a diagnostic “time out” can result in improved patient safety.



3.

How workplace learning theory may contribute to reducing diagnostic error

Laura R.E. Chapman, Waitemata DHB,Auckland, NZ and Dept. of Medicine, University of Auckland

Background: The enquiry explores how workplace learning theory may contribute to resolving diagnostic error.Diagnostic error is common and significant. How clinicians learn about diagnostic error is largely unknown. Although several medical schools have recently incorporated clinical reasoning into their curricula, diagnostic error is not widespread on postgraduate curricula. Clinicians are not routinely educated on diagnostic error causation or resolution.Clinicians are exposed to diagnostic error at work thus knowledge is presumed to be predominantly acquired through work. How workplace learning may contribute to reducing diagnostic error has not been explored. This enquiry aims to examine the theoretical base of workplace learning, then explore the interplay between theories of workplace learning and diagnostic error to identify how workplace learning may contribute to reducing diagnostic error.Methods:Objectives:1. Review the theories of workplace learning2. Analyse current diagnostic error solutions using workplace learning theory3. Outline how workplace learning theory may contribute to future solutions for diagnostic error

MethodologyThe study was served by literature review with an unfolding, practical design. Theories of diagnostic error and workplace learning theory were reviewed before a discussion on the interplay.Results: Workplace learningFormal and informal learning (diagram 1) contribute to workplace knowledge leading to explicit and implicit knowledge (diagram 2).How workplace learning may contribute to reducing diagnostic errorCurrent proposed solutions encompass formal learning and acquirement of explicit knowledge which is less likely to be effective than a focus on informal learning leading to gain of implicit knowledge. Future solutions should absorb this concept and aim for contextual and cognitive fidelity to the workplace.Conclusion: Workplace learning theory suggests informal learning and implicit knowledge formation may be an effective way of acquiring knowledge about diagnostic error and through this, influencing change and reducing incidence.Workplace learning theory suggests current solutions for cognitive causes of diagnostic error are weak because they rely on formal learning processes. Current system-based solutions are because they aim for integration into practise allowing informal learning. Future solutions need to be guided by the principles of informal learning and the importance of gaining implicit knowledge by integrating into routine practice.Achieving implicit knowledge may need to start through formal learning in order to equip role models who can then model behaviour within the workplace – which allows others to learn. The discussion of the role of formal and informal learning in diagnostic error highlights the interaction between modes of knowledge and learning.



Diagram 1: Types of Learning in the Workplace

- implicit/unintentional (by exposure or experience)

- incidental (by-product of another activity)

- reactive (unplanned, near spontaneous, during activity)

- deliberative (planned unstructured, often following initiating activity)

Formal = structured, planned learning activity

Informal (non-formal) = unstructured and control rests with learner

Diagram 2: Summary of interaction between informal and formal learning

Formal Learning

Informal Learning (experience)

Adapted for use at work

Explicit Knowledge

Implicit Knowledge

Abstractionknowledge becomes conscious

4.

Healthcare improvement science: Can we provide more insight and better educate healthcare professionals?

Radu Crisan-Dabija, Diana Veronica Costache, Traian MihaescuClinic of Pulmonary Disease,Iasi Romania, University of Medicine and Pharmacy “Grigore T. Popa” Iaşi

Background: The improvement of healthcare quality and patient safety are clinical targets recognized by all healthcare professionals (HCP). The research to determine which improvement strategies are effective has been insufficient.The aim of ISTEW Project (http://www.uws.ac.uk/improvementscience) was to develop shared academic and practice based programs that enable European Universities to build improvement capability within their own healthcare workforce, through engagement with students.Objective: We focused on review of available education in the European partners’ countries (Scotland, Slovenia, Poland, Spain, Italy) in order to prepare an overview of each partner’s current Healthcare Improvement Science (HIS) education and/or training programs for healthcare professionals.Methods: We searched 10 electronic databases for research on HIS education and / or training published between 1980 and 2011. We reviewed 367 studies and contacted 60 Higher Education providers.First, a mapping tool was designed to gather information on existing HIS learning programs that are currently being delivered across Europe using the Bologna cycle descriptors and specific search terms and template fields were applied. We also sent out 62 online questionnaires to colleagues involved in the Healthcare Improvement Science research or education in an attempt to identify the programs from hidden cur-ricula (conferences, etc).Results: Most of the available relevant education was found within the post-graduate programs, the countries that included HIS related edu-cation in a higher proportion in undergraduate courses target particular healthcare disciplines (medical staff and nurses).England has the higher number of courses in multidisciplinary fields, followed by Spain, Romania and Poland. The main keyword for the English courses was “leadership” as for the other countries keywords like “management” and “improvement” were more frequent.Conclusions: In most countries, the academic environment has failed to produce continuous and sustainable curricula for the teaching of Healthcare Improvement Science.In all partner countries we have found examples of HIS education but we have not found any that have a systematic approach to the develop-ment of Improvement Science.These findings suggest the need to create an unified core curriculum in way that values each partner’s educational experience and knowledge and is adaptable to the particular cultural, socio-economic and health challenges found in each.


http://www.uws.ac.uk/improvementscience


5.

Diagnostic test strategies for inflammatory bowel disease in children presenting at primary care level

Gea A Holtman MSc1, Yvonne Lisman-van Leeuwen PhD1, Boudewijn J Kollen PhD1, Obbe F Norbruis2 PhD, Johanna C Escher Prof3, Laurence C Walhout BSc3, Angelika Kindermann PhD4, Yolanda B de Rijke PhD5, Patrick F van Rheenen PhD6, Marjolein Y Berger Prof1

1Department of General Practice, University of Groningen, University Medical Center Groningen, PO Box 196 – FA21, 9700 AD Groningen, the Netherlands.2Department of Pediatrics, Isala Hospital, PO Box 10500, 8000 GM Zwolle, The Netherlands.3Department of Pediatric Gastroenterology, Erasmus MC-Sophia Children’s Hospital, PO Box 2060, 3000 CB Rotterdam, the Netherlands.4Department of Pediatric Gastroenterology, Emma Children’s Hospital / Academic Medical Center, PO Box 22700, 1100 DE Amsterdam, the Netherlands.5Department of Clinical Chemistry, Erasmus MC, University Medical Centre, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands.6Department of Pediatric Gastroenterology, University of Groningen, University Medical Centre Groningen, PO Box 30001, 9700 RB Groningen, the Netherlands

Background: In children presenting at the primary care level with chronic diarrhea or recurrent abdominal pain, clinical history and physical examination are used to identify “red flags” of possible inflammatory bowel disease. C-reactive protein is commonly used to triage those children who need to be referred for specialist care. Fecal calprotectin is increasingly used to distinguish between func-tional gastrointestinal disorder and inflammatory bowel disease. We evaluated the added value of C-reactive protein and fecal calpro-tectin to red flags to determine the optimal referral strategy for specialist care in children suspected of inflammatory bowel disease. For that purpose we compared the following test strategies: 1) red flags, 2) red flags and C-reactive protein, and 3) red flags and fecal calprotectin.Methods: A prospective cohort study was conducted, including consecutive children aged 4-18 years with chronic diarrhea or recurrent abdominal pain referred to pediatric gastroenterology (n = 65 referred by general practitioners, n = 25 referred by general pediatricians). Outcome was defined as 1) inflammatory bowel disease confirmed by endoscopy, or 2) inflammatory bowel disease ruled out by either endos-copy or unremarkable clinical 12-month follow-up with no indication for endoscopy. Receiver operating characteristics and decision curves were used to compare the three test strategy probabilities generated by logistic regression analyses.Results: We included 90 children, of whom 17 (19%) had inflammatory bowel disease. Adding fecal calprotectin to red flags increased the area under the curve significantly from 0.80 (0.69–0.90) to 0.97 (0.93–1.00) (P = 0.002). C-reactive protein, when added to red flags, did not increase the area under the curve significantly. Decision curves confirmed these patterns and showed that a combination of red flags and fecal calprotectin is the diagnostic test strategy with the highest net benefit at all reasonable threshold probabilities (Figure 1).Conclusion: An evaluation of red flags and fecal calprotectin showed to be the optimal strategy for further stratifying children who have already been identified as at risk for inflammatory bowel disease by the general practitioner.

.2.1

5.1

.05

0

Net

Ben

efit

-.05

0 .1

Net Benefit: Treat All Net Benefit: Treat None

Net Benefit: Red flags + FCalNet Benefit: Red flags + CRPNet Benefit: Red flags

.2

Threshold Probability

.3 .4

Figure 1: Decision curve for three models predicting the outcome of IBD.Abbreviations: CRP: C-reactive protein, FCal: fecal calprotectin.



6.

Patients’ experiences of cancer diagnosis through emergency presentation: A qualitative study

Georgia Black1, Jessica Sheringham1, Naomi Fulop1, Vicki Spencer-Hughes2, Melanie Ridge3, Charlotte Williams3, Kathy Pritchard-Jones3

1UCL Department of Applied Health Research, UCL, London, England2LKSS Public Health Training Programme & Public Health Service, Lambeth and Southwark Local Authorities, London, England3UCL Partners, London, England

Background: Delays in diagnosis may contribute to poor UK one-year survival for common cancers compared to other similar nations. One particular cause for concern is that 25% of patients are diagnosed through an emergency presentation, i.e. after visiting an Emergency Depart-ment or an emergency admission to hospital. Short-term survival in these patients is poor compared with other routes to diagnosis even when age and case mix are taken into account. We aimed to find out more about cancer patients who experienced diagnosis through emergency pathways, in terms of personal factors, healthcare presentations and subsequent care.Methods: Eligible patients were identified in a service evaluation of emergency presentations and invited to participate. Interviews, using an open-ended biographical structure, captured 26 participants’ experiences before and after cancer diagnosis. We used Walter’s model of pathways to treatment as an organising construct in our thematic analysis.Results: The cancer pathway through emergency routes is complex and unstructured. We present three typologies of patients using this route that challenge the discrete stages presented in the Walter’s model. Most participants consulted a GP before their diagnosis. Participants often ascribed their emergency visit to factors outside their control, such as GP referral, or symptom crises. Emergency presentation was also a strat-egy for taking control or overcoming barriers in primary care. Our findings suggest there are avoidable breakdowns in diagnostic pathways.Conclusion: Our findings point to several potential areas of clinical improvement; in particular, a stronger emphasis is needed on diagnostic uncertainty in discussions between patients and doctors in both primary and secondary care. To improve appropriate access to rapid inves-tigations, systems are needed for primary care to communicate directly with secondary care at the time of referral. Lessons derived from this study in respect of strategies to improve emergency diagnosis of cancer can be applied to efforts to reduce emergency presentations of other diseases.

7.

Deliberate cognitive processing results in improved insight in patient problems; a randomized study on patient handoff.

Gwen van Heesch MD1, Joost Frenkel MD, PhD2, Wouter Kollen MD, PhD3, Laura Zwaan PhD4, Sílvia Mamede MD, PhD5, Henk Schmidt PhD6, Matthijs de Hoog MD, PhD7

1Department of Pediatrics, Erasmus MC – Sophia, Rotterdam, The Netherlands2Department of General Pediatrics and Pediatric Immunology, University Medical Center, Utrecht, The Netherlands3Department of Pediatrics, Leiden University Medical Center, Leiden.4Institute of Medical Education Research Rotterdam, Erasmus Medical Center, Rotterdam, The Netherlands5Institute of Medical Education Research Rotterdam, Erasmus Medical Center and Department of Psychology, Erasmus University Rotterdam, Rotterdam, The Netherlands6Institute of Psychology, Erasmus University Rotterdam, Rotterdam, The Netherlands7Department of Pediatrics, Pediatric Intensive Care Unit, Erasmus MC – Sophia, Rotterdam, The Netherlands

Background: Due to limits in working hours in the current healthcare system the number of care transfers is increasing. Transfer of care involves a handoff (or handover). The handoff has been indicated as a key factor in patient safety. Despite a rising attention for its importance, few residents receive formal education concerning handoff procedure. Only a small number of studies have evaluated educational interven-tions to improve handoff skills. Therefore, the aim of this study was to investigate the effect of an intervention that will lead to deliberate cognitive processing of received information during handoff procedure in a randomized setting.Methods: Residents from 3 academic hospitals were randomly assigned to intervention or control group. In phase 1, all participants received 8 written handoffs. Each handoff consisted of a short (300-400 words) description of a pediatric case. The participants in the intervention group received specific instructions to write down possible threats for the patient and to explain why they thought these threats existed. Afterwards, they were asked to write down a contingency plan. The participants in the control group did not receive specific instructions. In phase 2, all participants were asked to recall information from 4 handoffs. This information could be either idea units or inferences. An inference is a conclusion computed by the participant based on ≥ 2 idea units. In advance, each handoff was split into single idea units. The 4 cases together contained 205 idea units. The percentage and accuracy of recalled idea units was the primary outcome. Secondary outcome was the amount of correctly created inferences.Results: A total of 78 pediatric residents participated. The participants in the intervention and control group were comparable with regards to baseline characteristics. Participants in the intervention group significantly recalled less correct idea units (21.1% vs 25.3%; p = 0.016),



whereas no difference was noted for incorrect units. However, they significantly created more correct inferences (7.6 vs 3.5; p < 0.001), (no dif-ference was noted for incorrect inferences). See table 1.Conclusion: This intervention study shows that residents who deliberately process received information during handoff recall less informa-tion elements. Despite they remember less, they are able to create more correct inferences about the patients transferred. This might imply improvement of comprehension of the patients transferred in handoffs and improvement in quality of the handoff in general. Future research should further investigate the effect of such educational intervention in handoff in real-life situations.

Intervention

Control

p°

n % n %

All Idea Units 205 100 205 100 Correct recall of Idea Units 43.2 21.1 51.8 25.3 0.016Incorrect recall of Idea Units 2.9 1.4 3.5 1.7 0.245No recall of Idea Units 158.9 77.5 149.7 73.0 0.016Inferences 7.6 3.5 < 0.001Correct Inferences 7.3 3.3 < 0.001Incorrect Inferences 0.3 0.2 0.488

8.

Factors predicting a change in diagnosis in patients hospitalized through the emergency room

Wolf Hautz1, Stefanie Hautz2, Juliane Kämmer3, Luca Schuler1, Thomas Sauter1, Volker Maier4, Tanja Birrenbach5, Stefan Schauber6, Meret Ricklin1, Aristomenis Exadaktylos1

1Inselspital, University of Bern, Department of Emergency Medicine2Medical Faculty, University of Bern, Institute of Medical Education, Department of Evaluation and Assessment3Max Planck Institute for Human Development, Center for Adaptive Rationality & Charité Universitätsmedizin Berlin, AG Progress Test Medizin4Inselspital, University of Bern, Department of General Internal Medicine5Inselspital, University of Bern, Department of Emergency Medicine & Inselspital, University of Bern, Department of General Internal Medicine6University of Oslo, Faculty of Educational Sciences, Centre for Educational Measurement

Background: Diagnostic errors contribute substantially to preventable medical error. The estimated rate varies from below 5% in ‘visual’ spe-cialties to around 15% in contexts like the emergency room (ER). Faulty clinical reasoning may be related to a misalignment between a physi-cian’s confidence in and the actual accuracy of a diagnosis. Field studies on determinants of diagnostic errors and on the informativeness of physician confidence are still rare. With the current study we aim to identify factors that predict an ER’s diagnostic performance.Methods: We are currently conducting a single centre observational field study in which we collect diagnostic decision data, physician confi-dence and a number of influencing contextual factors. We aim to model diagnostic decisions and investigate the adequacy, validity and infor-mativeness of physician confidence in these decisions. Specifically, we are collecting data for 500 patients admitted to an internal medicine ward (IM). A change in the lead diagnosis and the admitting physician’s confidence at the time of ward admission are the primary dependent variables of this study that we a) correlate and b) model through all other collected data in a linear mixed effects model. Data collection will conclude in April 2016 and first results will be available for discussion at the conference. We further conducted a similar retrospective pre-study, results of which are presented below.Results: During the pre-study period (Jan – March 2015), 186 patients were admitted from the ER to IM wards. Of 90 randomly selected patients, four did not fulfil the main studies inclusion criteria and were thus excluded. To assess the rate of change in diagnosis, two inde-pendent raters compared the ER’s admittance diagnosis to the IMs’ discharge diagnosis and achieved good agreement (kappa = 0.61). In 16.3%, a change in diagnosis was observed. The table lists the absolute and relative frequencies with which pairs of ER/IM diagnoses were assigned to rating categories:Conclusion: Research on diagnostic error is difficult to conduct for several reasons, including the relatively low frequency of consequential errors. Previous studies on diagnostic error are thus often limited to the assessment of either cognitive or contextual factors. In the current study, we focused on change in diagnosis instead of diagnostic error under the assumption that errors are a subset of all cases where the diagnosis changed. Factors that predict a change in diagnosis may thus inform future research on diagnostic error.



n = frequency; % = Percentage

IM discharge diagnosis compared to ER diagnosis is: n %

identical 27 31.4a precision 33 38.4a complication 2 2.3a change in hierarchy 9 10.5a change in diagnosis 14 16.3not classifiable 0 0sum 85 100

9.

Diagnostic errors in dermatology occur with both common and uncommon diagnoses

James S. Taylor1, Melissa Piliang1, Allison T. Vidimos1, Christine B. Warren1, Anthony P. Fernandez1, Alok Vij1, and Stephen E. Helms2

1Cleveland Clinic Lerner College of Medicine2University of Mississippi Medical School

Background: Outside of the malpractice arena, diagnostic errors in dermatology have received little attention, because they are more difficult to define, measure, and fix (Wachter 2012).Methods: Seven dermatologists were surveyed via email to identify the first example or two of diagnostic errors that came to mind and to classify them as no fault, systems-related, cognitive bias or a combination (Graber 2005).Results: Nine cases were identified by diagnosis (and classification): 1: frontal fibrosing alopecia presenting as sarcoidosis (no fault unusual presentation and cognitive confirmation bias); 2-4: three cases of allergic contact dermatitis: two from hair dye- one presenting as marked angioedema of the face and the other as tinea capitis with cellulitis resistant to antifungal therapy(anchoring and availability biases), and a third from shoes- initially with contact allergy to chrome-tanned leather and later to an additional allergen, the topical corticoid used to treat the dermatitis(diagnosis momentum); 5: benign familial pemphigus diagnosed and treated as psoriasis (availability and overconfidence biases);6-8: three cases of urticarial pemphigoid diagnosed as recalcitrant contact dermatitis, neurotic excoriations and psoriasis (anchoring and availability biases; and 9: invasive microcystic adnexal carcinoma of an extremity diagnosed following review of pathology slides from permanent histologic sections of the tumor obtained during Mohs micrographic surgery for removal of putative recurrent basal cell carcinoma (systems related and anchoring and confirmation biases).Conclusions: Of the initial diagnoses most were one or more cognitive mistakes by non-dermatologists more than by dermatologists. Case 1 was no-fault plus other cognitive biases. Contact dermatitis is one of the most common medical diagnoses and is sometimes diagnosed as an infection (cases 2 and 3). The angioedema in case 2 was also suggestive of type 1 rather than type 4 allergy. Patch testing is the gold standard to diagnose type 4 allergy and is often underutilized. Case 5 was solved after further patch testing with the patient’s new topical medication. Definitive diagnoses in cases 6-8 were made by obtaining skin biopsy specimens for routine and direct immunofluorescence. Systems issues were operative in case 7 with failure to do permanent t issue stains during initial Mohs surgery and by pathologic misdiagnosis. Improved diagnoses in cases 1-9 involve teamwork, education and training (Institute of Medicine 2015), and use of diagnostic checklists (Ely 2011, 2014 and Winters 2011) and in case 9 of following published Appropriate Use Criteria for Mohs Micrographic Surgery (Connolly et al 2012).

10.

How much overtesting is needed to safely exclude a diagnosis? A different perspective on triage testing using Bayes’ theorem

Jonne J Sikkens1, Djoeke G Beekman1, Abel Thijs1, Patrick M Bossuyt2, Yvo M Smulders1

1Department of Internal Medicine, VU university medical centre, 1081HV Amsterdam, the Netherlands2Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Centre Amsterdam, 1105 AZ Amsterdam, the Netherlands

Background: Ruling out disease often requires expensive or potentially harmful confirmation testing. For such testing, a less invasive triage test is often used. Intuitively, few negative confirmatory tests suggest success of this approach. However, if negative confirmation tests become too rare, too many disease cases could have been missed. It is therefore important to know how many negative tests are needed to safely exclude a diagnosis.



Methods: We quantified this relationship using Bayes’ theorem, and applied this to the example of pulmonary embolism (PE), for which triage is done with a clinical decision rule and D-dimer testing, and CT-angiography (CTA) is the confirmation test. To estimate the uncertainty associated with our outcomes, we performed a Monte Carlo simulation study by replicating the diagnostic study from which we used the test characteristics.Results: For a maximum proportion of missed PEs of 1% in triage-negative patients, we calculate a 67% (95% confidence interval 32-81%) ‘mandatory minimum’ proportion of negative CTA scans. To achieve this, the proportion of patients with PE undergoing triage testing should be appropriately low, in this case no higher than 24%.Discussion: Pre-test probability, triage test characteristics, the proportion of negative confirmation tests, and the number of missed diagno-ses are mathematically entangled. The proportion of negative confirmation tests—not too high, but definitely not too low either—could be a quality benchmark for diagnostic processes.

11.

Guided reflection interventions for diagnostic accuracy: A systematic review and meta-analysis

Kathryn Ann Lambe1, Gary O’Reilly2, Brendan D Kelly3, Sarah Curristan4

1School of Psychology, Trinity College Dublin, Ireland2School of Psychology, University College Dublin3School of Medicine, Trinity College Dublin, Trinity Centre for Health Sciences, Tallaght Hospital, Dublin, Ireland4School of Psychology, Trinity College Dublin

Background: Diagnostic error is common in medical settings, with enormous human and economic costs. The dual-process model of ana-lytical and non-analytical reasoning provides a framework for understanding the diagnostic process and attributes certain errors to faulty cognitive shortcuts, or heuristics. The literature contains many suggestions to counteract these and to enhance analytical and non-analytical modes of reasoning, and recent review work suggests that interventions promoting guided reflection during diagnosis may be among the most successful. This study expands on our previous systematic review to identify, describe and appraise the range of studies that have empirically investigated such interventions and to assess their effectiveness by meta-analysis.Methods: Systematic searches of five databases were carried out (Medline (Ovid, 1990– present), PsycInfo (Ovid, 1990–present), Embase (Elsevier, 1990–present), ERIC (Education Resource Information Centre) (ProQuest, 1990–present) and the Cochrane Database of Controlled Trials (Wiley, 1990– present)), supplemented with searches of bibliographies and relevant journals and correspondence with authors. Studies were included in this analysis if they formally evaluated an intervention to enhance analytical reasoning through guided reflection among medical trainees or doctors.Results: Five guided reflection studies were included. Pooled analysis was carried out using a random effects model. We found evidence for small improvements in diagnostic accuracy for participants using guided reflection compared to intuitive reasoning (Hedge’s g = 0.237, 95% CI, -0.051 - 0.524). Existing studies are largely limited to early-career doctors and four of the studies included were conducted by significantly over-lapping research teams.Conclusions: Results to date are promising and this relatively young field is now close to a point where these kinds of cognitive interventions can be recommended to educators. Further research with refined methodology and more diverse samples is required before firm recommenda-tions may be made for medical education and policy; however, these results suggest that such interventions hold promise, with much current enthusiasm for new research.

12.

Seek, and you will find

Urara Nakagawa1, Toshiaki Wakai2, Dongkyung Seo1, Masaji Saijo1, Dongje Seo3

1Tanabe, Yasushi Sapporo Tokushukai Hospital, Sapporo, Japan2Ohasa Clinic, Ebetsu, Japan3SeoDankook University college of Medicine, Cheonan, South Korea

Background: Bacterial vertebral osteomyelitis (BVO) may be difficult to be detected. In fact, previous studies revealed it took 11.6 - 49.7 days for diagnosis of BVO. The aim of this study was to identify factors to hasten diagnosis of BVO.Methods: This was a retrospective cohort study of 18 patients, mean age of 70.5 ± 12.5 years, in a Japanese community hospital. Electronic medical records (EMR) of patients with diagnosis of BVO by MRI or CT, from April 2011 to March 2014, were reviewed. Factors including age, sex, comorbidities, pathogens, results of cultures and documentation of BVO as tentative diagnosis in EMR at the initial visit, were evaluated. Paired t-test for interval variables, chi-square test for categorical variables, and odd ratios were calculated.



Results: Of 18 patients with diagnosis of BVO by MRI or CT, average duration from the onset of back pain before the visit to medical institu-tions was 6.44 days, and the one from the first visit before the diagnosis was 22.4 days. 9 (50.0%) were diagnosed 14 days or longer after the first visit before the diagnosis and no one (0%) had the documentation of BVO. Meanwhile, 9 (50%) were diagnosed within 14 days after the first visit before the diagnosis and 5 (55.6%) had the documentation of BVO. By univariate analysis, the odds ratio was 3.250 [p < 0.015, 95%CI: 1.438-7.345]. 18 (100%) patients had back pain, however, 8 patients (44.4%) had the other chief complaint. Only 5 patients (27.8%) had fever ( > 38.0C) on arrival. 6 patients (33.3%) did not reveal findings of infection on initial images (5 MRIs, 1 CT), which were diagnosed by repeated images in average of 30 days. 16 patients (88.9%) had positive results of blood cultures, and in 5 patients (27.8%) of them MRI or CT were repeated because of the positive results of blood culture.Conclusion: This study revealed the documentation of BVO was the most associated with the duration from the first visit before the diagnosis. Therefore, it may imply differentiating BVO is meaningful to hasten the diagnosis. It is not uncommon to initially present with atypical chief complaints, however, majority of patients had positive results of blood cultures, some of which necessitated immediate MRI or CT. It took longer to repeat images once BVO was regarded less likely in initial images due to premature closure. Furthermore, it is crucial not to exclude BVO completely until proven otherwise.

13.

In the blink of an eye: Rapid visual diagnosis in medicine

Sandra Monteiro, PhD - Assistant Professor1, Akeel Ali, MD2, Jonathan Sherbino, MD – Associate Professor3, Matthew Sibbald, MD – Assistant Professor4, Karen Finlay, MD – Associate Professor2, David Koff, MD – Chair2, Geoffrey Norman, Professor Emeritus5

1Clinical Epidemiology and Biostatistics2Radiology3Emergency Physician4Cardiology5Clinical Epidemiology and BiostatisticsAll authors are affiliated with McMaster University, Hamilton, Ontario, Canada

Background: Classic research in cognitive psychology contrasts two cognitive processes; one that is rapid and unconscious (System 1) with another that is slower and analytic (System 2). Critically, System 1 is theorized to recruit experiential knowledge, while System 2, is theorized to integrate knowledge of rules. Using written cases, researchers have made unsuccessful attempts to isolate the effects of each process on diagnos-tic reasoning. In visual diagnosis however, perceptual processing can precede conscious thought, leading physicians to be strongly influenced by early visual perception when determining if there is any underlying pathology to investigate. In this context, it may be possible to isolate the effect of System 1 by limiting the amount of conscious visual processing time (i.e. System 2). If this is possible, physicians with greater experi-ential knowledge should outperform less experienced diagnosticians only when conscious, visual processing time is restricted. The goal of the current pilot study is to understand the relationship between experience, System 1 processing and accuracy in detection of abnormal images.Method: To modulate use of System 1 compared to System 2 visual processing, we used a speeded protocol in which participants viewed x-rays for very short durations of time. Twenty normal and 20 abnormal images of lungs were randomly assigned to one of four viewing dura-tions: 175 msec., 250 msec., 500 msec., and 1000 msec. Seven diagnosticians, ranging in diagnostic expertise from staff physician to second year Radiology residents, were asked to categorize each image as normal or abnormal. Hits and false alarm rates were used to calculate d’ (sensitivity) for each level of experience at each viewing duration.Results: At the shortest viewing duration of 175 msec., the staff physician (d’ = 2) outperformed all levels of residents (d’ < 1.5). Critically, most residents performed at chance at the smallest viewing duration. Additional data are being collected to confirm this pattern. There was no dif-ference in overall accuracy between experience levels (p > 0.05) as the average score was 87% for residents and 85% for staff.Conclusions: This pilot study is a novel approach to isolating the effect of direct experience on clinical expertise. The results point to a benefit of System 1 processing as increased experiential knowledge resulted in more sensitive early detection of abnormal images. This early detection process may be linked to more accurate visual diagnosis in more complex cases.

14.

Clinical decision making in paramedicine: What happens when medical directives do not apply?

Michael Eby, Sandra Monteiro, Geoffrey Norman, Walter TavaresMcMaster University, Hamilton, ON, Canada

Background: In Ontario, Canada, paramedics are required to adhere to a series of provincial medical directives when making rapid clini-cal decisions. Critically, they have limited autonomy to treat patients who do not fit those directives, with unsupervised deviation from the



directives classified as a form of error and highly discouraged. To date, there is little known about how experience affects the way these medical directives are followed. The purpose of this study was to examine the relationship between paramedic experience and adherence to directives.Methods: Thirty-one participants (16 expert / 15 novice) were recruited from two paramedic services in Ontario. Expertise was defined as in-practice for 5 years or more. Participants were presented with 9 scenarios; in 6 scenarios, the patient presentation fit within clearly defined directives, while in 3 scenarios, the patient presentation fell outside the medical directives but still required treatment. Multiple-choice responses were used to capture participants’ decisions to adhere to the directives. Responses were scored and submitted to a t-test to evaluate differences in accuracy between scenario types.Results: There was a significant effect of scenario type (p < 0.001). Accuracy was lower when the patient presentation did not meet the criteria of the medical directive (78% (CI = 72% to 84%) vs. when they did 98% (CI = 94% to 100%)). There was no effect of expertise and no interaction.Conclusion: Contrary to findings in expertise research, these results point to experience dependent practice that is not related to number of years in practice. The results suggest both novice (junior) and expert (senior) paramedics are able to accurately follow medical directives, however, there is a large variation in practice when the patient presentation does not fit one. This variation may have a significant impact on patient safety, and further research is required to determine what factors are causing this decreased accuracy.

15.

Missed diagnostic opportunities and English general practice: a study to determine their incidence, confounding and contributing factors and potential impact on patients through retrospective review of electronic medical records

Sudeh Cheraghi-Sohi, Hardeep Singh3, David Reeves2, Jill Stocks1, Rebecca Morris1, 2, Aneez Esmail1, 2, Stephen Campbell1, 2, 4, Carl de Wet5

1NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, University of Manchester, 7th Floor: Williamson Building, Manchester2Centre for Primary Care: Institute of Population Health, University of Manchester, 7th Floor: Williamson Building, Manchester3Houston Veterans Affairs Centre for Innovations in Quality, Veterans Affairs Medical Centre and Baylor College of Medicine, 2002 Holcombe Blvd. 152, Houston, USA.4Centre for Research and Action in Public Health (CeRAPH), University of Canberra, Building 22, Floor B, University Drive, Bruce, ACT 2617, Australia.5School of Medicine, Gold Coast Campus, Griffith University, Queensland, Australia.

Background: Diagnostic errors are thought to be common in primary care, however data about the incidence, types and causes of such errors are scant. To date there are no large-scale epidemiological studies in the UK which reliably quantify diagnostic error and associated rates of harm in primary care. Diagnostic error rates vary according to how ‘error’ is defined but one suggested hallmark is clear evidence of ‘missed diagnostic opportunities’ (MDOs) to make a correct or timely diagnosis to prevent them. While there is no agreed definition or method of measuring MDOs, retrospective manual chart or patient record reviews are a seen as a ‘gold standard’ approach. This study aims to use record review to: (1) determine the incidence of MDOs in English general practice, (2) identify the confounding and contributing factors that lead to MDOs and (3) determine the (potential) impact of the detected MDOs on patients.Methods: A two-phase, retrospective review of electronic health records (EHRs) in the Greater Manchester (GM) area of the UK. In phase one, clinician reviewers calibrate their performance in identifying and assessing MDOs against a ‘primary reviewer’ using a double record review approach. Phase one is designed to enable a preliminary estimate of the incidence of MDOs in English general practice, which will be used to calculate the number of records to be reviewed in the second phase in order to estimate the true incidence of MDO in general practice. A sample of 15 general practices is required for phase 1 and up to 35 practices for phase 2. In each practice, the sample will consist of 100 patients aged ≥ 18 years on 1 April 2013 who have attended a face-to-face ‘index consultation’ between 1 April 2013 and 31 March 2015. The index con-sultation will be selected randomly from each unique patient record, occurring between 1 July 2013 and 30 June 2014.Results: This is an ongoing study and as such, we will present: 1) some preliminary data regarding any MDOs identified to date, 2) discussion around the progress and feasibility of conducting such studies in relation to the setting of UK general practice and 3) ideas for future work generated from the study.Conclusion: As there are no reliable estimates of MDOs in UK general practice, this study will lay the foundation for targeting safety improve-ments in this area by providing a more reliable estimate of MDOs, their impact and their contributory factors.



Posters presentation June 30, 17.15-18.15h Applied Innovations



16.

Structured clinical pattern recognition in computer-aided diagnosis and a learning healthcare system

Amos CahanIBM T.J Watson Research Center

Statement of problem: Physicians intuitively diagnose by applying pattern recognition. A pattern emerges from the clinical findings and their temporal and semantic inter-relations. Clinical patterns must be put in context of the prior probability of encountering the diseases they suggest, yet physicians often exhibit flawed probabilistic reasoning. These challenges are reflected in high rates of deadly and costly diagnosis errors.Introduced over 50 years ago, diagnosis support systems are still not routinely used in general medicine clinical diagnosis-making. These systems cannot efficiently apply pattern recognition diagnosis and are unable to consider the base rate when ranking possible diagnosis. Moreover, their use is poorly aligned with the clinical workflow.Description of the intervention or program: We portrait Next Generation diagnosis support systems and provide a conceptual framework for their development. We argue for real-time construction of structured patient patterns through a physician-machine interactive process and outline a cognitive computing approach to facilitate this process in a workflow-compatible manner.We call for a distributed knowledge generation and maintenance model, wherein each patient pattern enriches the knowledge base. Auto-matically de-identified structured patient patterns can be safely shared and reused across physicians and institutions, making the collective experience of physicians worldwide available to support pattern recognition-based diagnosis. The collective pattern map can also serve as a living epidemiologic database, providing real time disease surveillance and disease base rate estimates (Figure).We explain how healthcare in resource-limited settings can benefit from using this approach and how it can be applied to provide feedback-rich medical education for both students and practitioners.Findings to date: N/ALessons learned: N/A

Figure: Generating a real time structured representation of a patient presentation supports a computer-aided diagnostic process and a learning healthcare system through knowledge reuse



17.

Improving HIV testing in patients with invasive pneumococcal disease

Chelsea Carr, Medical student1, Dr J Williams, Consultant ID Physician2

1Newcastle University2JCUH, Middlesbrough

Statement of problem: Late diagnosis of HIV is associated with worse outcomes for patients. Root cause analyses of these diagnostic errors often reveal missed opportunities for earlier diagnosis. British HIV Association testing guidelines recommend HIV testing for all cases of TB and lymphoma and many “indicator conditions” including bacterial pneumonia. Public health data suggest that 2.5% cases of invasive pneumococcal disease in the UK are associated with HIV. We practice in an area of the UK with low HIV prevalence, below the level where screening is recommended.Description of the intervention or program: Since 2012 we have audited HIV testing rates in cases of invasive pneumococcal disease (IPD) diagnosed in our microbiology laboratory and in patients attending the local TB and lymphoma clinics. Several interventions have been implemented to try to increase testing rates. Over the past four years we have delivered educational sessions to medical students, hospital medical staff, General Practitioners, Haematologists and Respiratory physicians. Nurse-led HIV testing has been introduced in TB and lym-phoma clinics. All positive pneumococcal results now contain advice to consider HIV testing. We are working on developing a prompt for our electronic pathology requesting system that suggests HIV testing if clinicians are ordering tests for indicator conditions.Findings to date: Nurse-led testing has been successful in increasing rates of HIV testing in the TB and lymphoma clinics (20% to 94%, 14% to 94% respectively). Testing rates of patients with invasive pneumococcal disease remain low overall. Although rates in some clinical areas are increasing, testing rates in Primary Care remain very low. Neither educational interventions nor the prompt on the pathology result appear to have had significant impact on overall testing rates.Lessons learned: General practice and Acute medicine are high risk areas for diagnostic error. The wide range of possible clinical presenta-tions and relative rarity of HIV ensures that, for most clinicians practicing in these areas, the possibility of HIV remains “out of sight and out of mind”. A prompt attached to positive lab results appears to have had little effect in increasing testing overall. Educational interventions appear to have more impact when delivered to small teams (eg Haematology, TB, ICU) than large groups (eg 50 local GP surgeries).

70

60

50

40

30

20

10

0<30 31–40 41–50 51–60 61–70 >70 <60

Age (years)

HIV testing followingIPD by age of patient

Not tested 2015

Tested 2015

% Tested 2012

% Tested 2013

% Tested 2014

% Tested 2015

18.

An evaluation of use of student response systems in teaching diagnostic reasoning

Tzu-Yao Hung1, Li-Wei Lin2, Chaou-Shune Lin3,4, Ching-Feng Su3

1Emergency Department, Taipei city hospital, Zhongxing branch2Emergency Department, Shin Kong Wu-Ho-Su Memorial Hospital3Emergency Department, Hsinchu Cathay General Hospital4School of Medicine, Fu Jen Catholic University

Statement of problem: One of the teaching strategies that facilitates learners’ procurement of the necessary skills for effective diagnostic reasoning is encouraging students to discuss their thinking process. Many studies have demonstrated that student response systems (SRSs) are useful for enhancing learner engagement. SRSs are small hand-held devices with which learners may remotely respond to questions that are posed during lectures. However, application of this tool in teaching diagnostic reasoning has not been explored. The aim of this study is to examine the perspectives and experiences of learners who used SRSs in a diagnostic reasoning class.



Description of the intervention or program: An experimental study was conducted in 2016 of a 4-hour training course in “Improving physi-cians’ diagnostic process,” which included 30 physicians. The Zuvio multimedia online interactive system was adopted in the class. The learners could use any type of smartphone or tablet to respond to the questions posed by the instructor on a computer screen that could be projected for other students to view. A 5-point scale quantitative questionnaire was designed to explore the views points of learners regard-ing students’ involvement, learning, and assessment. In addition, the learners were requested to write a brief qualitative feedback form that included two sections: (1) the benefits, (2) the challenges in using SRSs.Findings to date: A total of 29 students (response rate, 82%) completed the questionnaire at the end of the course. The results revealed that the main benefits of using SRSs were that the students felt comfortable while expressing their ideas in a big class and could obtain feedback from peers and the instructor immediately. However, the main challenges were that some questions from the instructors were not easy to understand. The quantitative data is summarized in Table 1.Lessons learned: The SRSs are easy to implement in teaching diagnostic reasoning and positively impact learning.

Table 1: Summary of the impact of using SRSs in a teaching diagnostic reasoning class

Description Mean ± SD

More focused in class 4±0.6More engaged in class 4.3±0.7Participated more with peers in class 4.4±0.6Participated anonymously 4.3±0.5Interacted more with peers to discuss ideas 4.1±0.9Actively discussed misconceptions 4.1±0.8Instructions that could be modified based on feedback from students 4.2±0.7Increase in learning performance 4.2±0.6Qualitative difference when learning with SRSs 4.2±0.6Provision of regular feedback 4.1±0.6

19.

Reducing diagnostic error in medicine through the integration of systems and cognitive processes

Mark Gusack, M.D., Staff PathologistDepartment of Pathology and Medicine Laboratory Services, Veterans Affairs Medical Center, Adjunct Clinical Professor, Marshall University School of Medicine

Statement of problem: Identification, characterization, and management of Diagnostic Error in Medicine is hampered by the lack of a unified approach. This is due, in great part, to the separation of the fields of systems management and cognitive psychology. The result; a combination of inadequate taxonomy and gaps in error reduction methodologies.Description of the intervention or program: An in depth review of the literature covering both systems and cognitive aspects of error was made. This included the fields of health care, aerospace, air traffic control, rail road control, and nuclear facility control. The knowledge acquired from this review provided the means to consolidate systems and cognitive error into a single unified taxonomy. This classification shows great promise as an effective framework for the application of available management tools to identify and reduce Diagnostic Error in Medicine.Findings to date: A first attempt at classifying Diagnostic Errors in Medicine has been completed utilizing a variety of sources in the litera-ture. Operational management tools matched to the taxonomy is proposed with an example application.Lessons learned: In order to significantly reduce Diagnostic Error in Medicine, it is necessary to:

– Do an exhaustive review of a broad range of human activities outside the healthcare field to more fully understand the problems we face. – Establish a unified taxonomy of and methodology for identification, characterization, and management of errors. – Develop the operational tools that integrate systems redesign and professional redevelopment into a single highly effectively effort to

reduce Diagnostic Error in Medicine.

20.

Reducing diagnostic error in medicine through implementation of an electronic knowledge repository

Mark Gusack, M.D., Staff PathologistDepartment of Pathology and Medicine Laboratory Services, Veterans Affairs Medical Center, Adjunct Clinical Professor, Marshall University School of Medicine



Statement of the problem: Reduction of errors in a large complex activity like health care requires a clearly defined and well maintained core of knowledge that is disseminated throughout the system. This is achieved through knowledge management. Although well-established in most areas of high risk human endeavor, knowledge management is all but ignored in the healthcare field. Yet it is the healthcare field that is most in need of such management. In particular, if we are to be successful in significantly reducing Diagnostic Error in Medicine, we must establish a means of gathering, validating, organizing, and disseminating knowledge to reduce Diagnostic Error in Medicine.Description of the intervention or program: I am presently working with a group of librarians/cyberians across the country under the auspices of Dr. Mark Graber,President, Society for the Improvement of Diagnosis in Medicine. We are designing and testing a model Electronic Knowledge Repository [eKR] targeting this problem. At this time, we have defined the scope of the problem as well as the projected capabilities and functionality of a knowledge management program based upon a relational database management system [RDMS] over which is being written a distributable knowledge acquisition and retrieval application.Findings to date: So far we have developed:

– A model database design to store and retrieve knowledge related article references, audio, images, and text. – A proposed user interface with simple pushbutton access to each function. – A set of basic capabilities to store, query, report and manipulate various forms of knowledge.

Lessons learned: – The health care field lags far behind other fields in the realm of knowledge management to reduce Diagnostic Error in Medicine. – The lack of this capacity prevents our profession from making significant strides in reducing Diagnostic Error in Medicine. – The development of a knowledge management model provides the means of gathering, evaluation, and dissemination of proposed

causes and solutions to Diagnostic Error in Medicine.



Posters presentation July 1, 12.00-13.00h Clinical Vignettes



1.

Heuristics or analytical?

Diana Veronica Costache, Traian MihaescuClinic of Pulmonary Disease, Iasi, Romania

Learning objectives: Determining the correct diagnostic can be sidetracked by atypical disease presentations or by diseases unseen by which the doctor. This is why all of the trained medical staff should collaborate by making use of their own references in order to reduce the incidence of misdiagnosis.Case information: We present the case of a 20-years-old man, presented to our hospital during the testing of a clinical decision support system for medical students and young doctors. The patient showed a stage I dyspnea (mMRC scale), emphasized under effort and accompa-nied by chest pains installed 2 days prior to his arrival at the hospital. The symptoms appeared after the patient underwent a medium physical effort. In the two days prior to arriving at the hospital, the patient was consulted by a general physician who, after not taking an X-Ray due to limited resources, performed a clinical exam after which he concluded that the pain was caused by a dose of effort followed by muscular fever. After this examination, the patient had also received indications from a pharmacist that he should take a combination of potassium and magnesium which would relieve his chest pain. After doing so, the pain indeed diminished.While the senior doctor performed the clinical exam, which revealed pale teguments, diminished breath sounds with a peripheral oxygen saturation of 97% and a heart rate of 98 bpm, the young doctor introduced the collected data in the clinical decision support system, which outlined a pneumothorax as a potential diagnosis. The chest X-ray revealed a massive bilateral pneumothorax which led to addressing the patient to thoracic surgery!Discussion: Although the patient arrived at the hospital on his own and the correct diagnostic and remedy were given in time, the conse-quences could have been disastrous if he might have decided to just follow the initial treatment. This presentation showcases the importance of medical staff collaboration and regular use of Clinical Decision Support Systems in reducing the incidence of misdiagnose.

2.

A case of hospital care - Unintended harm

Radu Crisan-Dabija, Diana Veronica Costache, Traian MihaescuClinic of Pulmonary Disease, Iasi, Romania, University of Medicine and Pharmacy “Grigore T. Popa” Iaşi

Learning objectives: The medical errors and the unintended harm are costly sideslips and result in money spent with prolonged hospitaliza-tion and additional treatment.The lack of personnel, the crowded and overwhelmed hospitals and the increased procedural steps and bureaucracy are contributors to medical errors.Case information: We present a case of a 78 years old woman, with mixed dementia and internalized in a permanent mental health sanato-rium, with a history of COPD and chronical respiratory failure with long term oxygen-therapy. She was admitted to the Clinic of Respiratory Diseases after acute onset and rapidly progressing dyspnea, cough with difficult expectoration and alteration of general status.The evolution was favorable after 10 days of treatment, O2 saturation reverting to 96% with 2 LO2/min. The day before her release, at the morning round we found out that she presented a saturation of 87% with same amount of oxygen and while increasing the O2 flow to 3 then 4 L/min, the peripheral saturation was the same.We found out that after the administration of aerosols the night before, due to the fact that the aerosol mask was connected with a separate tube to the same O2 source with the O2-therapy mask, the nurse mixed the two tubes. She set the O2-mask on the patient but the O2 source remained connected to the aerosols mask, so our patient did not receive O2 for almost 12 hours.Discussion: Although no permanent physical damage was done, the hospitalization of this patient was prolonged with another 2 days. If there would have been more nurses that had more rounds, this error could have been corrected earlier. We cannot possibly make procedures for every unintended harm we discover but we can have an ongoing process of revision of our currently procedures by communicating this kind of errors.

3.

TB or not TB? – that is the error!

Diana Veronica Costache1, TraianMihaescu1, Stefana Cristina Alexoaie2

1Clinic of Pulmonary Disease, Iasi, Romania2“Sfanta Maria” Emergency Hospital for Children, Iasi, Romania



Learning objectives: In order to reduce the prevalence of diagnostic errors, healthcare professionals need to improve the collaboration involving patients and their families, and steer the anamnesis.Case information: This paper reveals an atypical case of an 87-years-old man with an insidious onset of dry cough, followed by intermittent changes of this symptom, over a period of 4 months that resulted in multiple nights with lack of sleep. At the time, the primary doctor docu-mented a stage 2 dyspnea (mMRC scale) and subjected the patient to a chest X-ray, spirometry test which turned out to be normal. Over the next 3 months, the patient returned 2 more times to the same clinic with a productive cough and worsening psychological state. The clinical exam revealed coarse crackles of the lungs, a peripheral oxygen saturation of 98% and a heart rate of 71 bpm. However, being deeply involved in the diagnostic process, the patient felt that the initial observations did not find his true affliction. The next step of the investigation was represented by a sputum exam, for which the patient provided samples which consisted mainly in saliva, which could not be processed in the laboratory. Therefore, the next course of action was a bronchoscopy exam, which produced yellowish white mucopurulent secretions, positive in optical microscopy for M.tuberculosis, that finally led to the correct diagnosis of bronchial tuberculosis, confirmed by the culture of the samples.Discussion: While TB is rare to encounter in the Western States, which makes it even harder to detect, tuberculosis is a common disease in Romania. However, the atypical presentation of the disease in this case have led to a misdiagnosis. The increasing number of MDR-TB cases may be also due to the diagnostic errors. The presentation of this case outlines that teamwork and perseverance are key factors in reducing diagnostic errors.

4.

So Visceral the Bias

Giles J, Akhtar JUniversity of Pittsburgh Medical Center

Learning objectives: Clinical reasoning is complex and multi-factorial and emotion can impact upon decision making. Visceral bias is described as the influence of affective sources of error on decision-making. Visceral arousal can lead to poor decisions.Case information: A 41-year-old man who was found down in his backyard intoxicated. He was found to laying in the grass and was calling his neighbors for help because of leg weakness. Patient presented with pain all over. He had been drinking alcohol but does not remember falling down. His physical examination showed him to have a 5/5 strength in his bilateral upper extremities and intact sensation. Lower extremity examination showed him to have variable strength. He did not have any sensory deficit even though he was complaining of paresthesias in his lower legs. His rectal tone was intact. He had a CT scan of the head which showed no acute intracranial finding. A CT scan of the cervical spine showed no fracture. There was degenerative disc disease C5-6. His CPK was mildly elevated at 347. His alcohol level was 259 mg/dl. His neurologic examination was thought to be inconsistent and the physician felt the patent was feigning his weakness. Patient was signed out to be discharged home when sober. The relieving physician was concerned about the clinical presentation and a cervical spine MRI was done. It showed severe central canal stenosis with evidence of cord injury. Patient underwent posterior cervical laminectomies with fusion.Discussion: Visceral arousal leads to poor decisions as clinicians may be misguided by their own emotions and state of mind. The influence of affective sources of error on decision-making has been widely underestimated. Countertransference, involving both negative and positive feelings towards patients, might result in diagnoses being missed. Medical decision making may be impacted by negative impressions of the mentally ill or intoxicated.

5.

A strong intuition is much more powerful than a weak test.

Seth N, Giles J, Akhtar JUniversity of Pittsburgh Medical Center, Pittsburgh, USA

Learning objectives: Many clinical decisions involve the use of intuition. Physicians sometimes base clinical decisions on gut feelings alone, even though there is little evidence of their diagnostic value. Although gut instincts cannot be quantified, they should be regarded as an integral part of patient assessment.Case information: A 64-year-old man presented with right upper quadrant discomfort for six months with weight loss. The initial workup included an ultrasound which was negative for gallstones and showed 2 small hepatic cysts. He was referred to a gastroenterologist who felt his symptoms were musculoskeletal in origin. He did an upper endoscopy which showed antral gastritis and a CT scan abdomen confirmed the hepatic cysts. The patient presented to the emergency room (ER) three months later with persistent pain. His exam was unremarkable and a repeat CT scan showed no definite acute intra-abdominal process. Patient was discharged home. However, the treating ER physician was concerned about his presentation and nondiagnostic tests. His intuition was that something was wrong. He called the patient back the next day and told him to follow up with a surgeon for exploratory laparotomy and set up the appointment. Patient’s gastroenterologist continued



with non-invasive testing and ordered a motility study which was also normal. Patient had increasing pain and a month later presented to the ER and underwent diagnostic laparotomy. There were several nodular densities in the peritoneal surfaces which were resected and biopsied. The surgical pathology showed diffuse malignant mesothelioma involving the peritoneum and the appendix.Discussion: Intuition plays a crucial role in professional decision making as a “gut instinct” allows the practitioner to look beyond test results and to be open to situations that don’t feel “quite right. Should physicians believe in their sense of intuition to override negative tests.? Gut feeling can play substantial role in the diagnostic process.

6.

Cerebral vein thrombosis missed and misdiagnosed

Castro A, Akhtar J, Hsieh M, Giles JUniversity of Pittsburgh Medical Center

Learning objectives: Cerebral Vein Thrombosis (CVT) has varied and atypical clinical manifestations, as a result of which misdiagnosis and missed diagnosis often occur. Diagnosis is missed because of the heterogeneity in clinical presentation and etiological factors. These varied and atypical clinical manifestations often pose difficulty in early diagnosis of CVT, as a consequence of which necessary treatment is delayed.Case information: A 27-year-old male presented to an outside hospital after he developed a popping sound in his head, followed by frontal headache and ringing in both ears. A CT scan of the head done was negative for acute intracranial findings. A diagnostic lumbar puncture done was negative for subarachnoid hemorrhage. Patient was treated symptomatically and discharged home. He presented back the next day with increasing headache and was admitted to the hospital for pain relief. Consulting neurologist noted the sagittal sinus to be a bit large. MRV brain showed sinus thrombosis.A 21-year-old female on oral contraceptive pills developed severe headache on the day of presentation. She had intermittent headaches over the past few weeks and was diagnosed with migraines. A head CT was read as no acute intracranial abnormality at outside hospital. Lumbar puncture (LP) was done after which she became unresponsive. She was transferred to a University Hospital with a diagnosis of subarachnoid hemorrhage versus meningitis. A review of her initial head CT from the outside hospital a showed a hyperdensity in the left transverse sinus concerning for a dural sinus thrombus. Patient underwent cerebral angiogram which showed extensive venous sinus thrombosis.Discussion: CVT is often unrecognised at initial presentation. The diagnosis may be missed or misdiagnosed unless a clinician keeps a high index of suspicion due to non-specificity of symptoms. Imaging plays a very important role in early diagnosis of CVT and thus helps in pre-venting neurological complications.

7.

Mysterious oral pain after eating the sperms of a squid

Ichiro Sekine1, Takashi Watari2, Yasuharu Tokuda3

1Department of Emergency Medicine, Shonan Kamakura General Hospital, Kanagawa, Japan2Postgraduate Clinical Training Center, Shimane University, Shimane, Japan3Japan Community Healthcare Organization, Tokyo, Japan

Learning objectives: Oral stings caused by squid sperm bags should be considered in patients with sudden onset of severe pain in the oral cavity after eating raw squids.Case information: A 33-year-old woman presented to the emergency department of our hospital with sudden onset of stinging pain in the oral cavity immediately after eating raw Japanese foods. Oral examination identified small (3-5 mm of diameter), spindle-shaped white organ-isms stuck on the mucosa of the cheek and soft palate and the surface of the tongue (Figure 1). Anisakiasis, a parasitic mucosal invasion by eating a raw fish, was initially suspected, but it was considered unlikely based on the different morphology. Additional careful history taking revealed that, just before developing oral pain, the patient consumed the internal organs of a raw flying squid (Todarodes pacificus). A final diagnosis of oral stings by the sperm bags of the squid was made. The organisms were pulled out with forceps and the stinging pain was allevi-ated and the wounds eventually healed in several days.Discussion: Although the incidence actually might not be rare, there have been few case reports of oral stinging by sperm bags of fresh squids. As Japanese Sushi culture is spreading all over the world, there will be greater risk of parasitic infection such as anisakiasis as well as oral mucosal stinging by the sperm bags of raw squids. The internal organs, specifically spermatophores, of squids should be removed if it is consumed raw to prevent risk of oral stings by the sperm bags. Careful history taking about the detailed contents of consumed foods is important to avoid the misdiagnosis. Hence, stinging by the consumption of squid sperms should be considered as a differential diagnosis in patients with sudden onset of pain in the oral cavity after eating raw squids.



8.

Atypical chest pain

Laurens-Alexander Schols, MD, Stephanie Klein Nagelvoort-Schuit, MD, PhDDept. Emergency Medicine, Erasmus MC, Rotterdam, The Netherlands

Learning objectives: Description of patient history in which afterwards a retrospect view is presented of necessary and possible unnecessary additional laboratory research and imaging to rule out serious possible diagnosis. In this case report, in the idea of a just culture, various reasons for decision making in the patient admission and follow up is presented.Case information: A 61 year old male was presented at the emergency ward of a large academic medical center in the middle of the night.By 02:00 AM in the morning emergency services were informed of a patient with acute chest pain which had started without previous com-plaints that day. Because of the fact that pain was increasing in intensity and seemed to increase with breathing activity an ambulance was scrambled to the house of our patient.When arriving at the patient’s house he was put into an ambulance bed and driven to the hospital.At handover in the hospital we were confronted with an anxious patient with increased breathing activity (25/min) and pain was located retrosternal and increased in intensity. He was increasingly sweaty and seemed nervous. At a scale of 1-10 he scored the pain at that moment a 7. Verbally we heard that the patient was only known in our hospital with an cardiac ablation and was using acetylsalicylacid 80 mg/day without specific reason. Ambulance personnel informed us about the fact that there was a large difference in measured blood pressure between the left and right arm. Left 140/70 mmHg and right 75/50 mmHg.Alarmed by this information we decided after a quick primary survey of addressing airway, breathing, circulation (measuring blood pressure and pulse only at one arm), neurological status and temperature to send our patient immediately to the CT-scan with a high risk of a thoracic aorta dissection or pulmonary embolism. Of course we gave our patient painkillers (1000 mg Perfalgan and 50 micrograms Fentanyl), but the chest pain was not decreasing. Also after giving a spray of nitroglycerine chest pain was not decreasing.After having ruled out that there was a dissection or PE at that moment we took laboratory information for cardiac ischemia and made an ECG to see if there were signs in the ECG of cardiac origin of the chest pain.Lab findings and ECG results are presented in supplement 1 and 2.No significant signs of cardiac ischemia were seen on our ECG, but of course at that moment still a NSTEMI-cardiac problem could be there so we decided to follow up cardiac markers after a few hours to see if they were rising.At the end of the night shift we saw there was no rise in cardiac enzymes and we sent the patient home with the diagnosis atypical chest pain.Discussion: In retrospect with the first information we received I noted that there was a strong “ jumping to conclusion” mentality from my side. The information we received at that moment was colored by the fact that all the information I received from paramedics was confirming my idea of something serious happening at that moment.

Figure 1:



Due to the fact that the presentation of the patient was confirming my pre-thoughts about possible diagnosis I decided to make a CT scan first and then do laboratory research and ECG. Given the fact that ambulance personnel did not see significant ischemia on the ECG I decided that it was more important to rule out a thoracic dissection or pulmonary embolism.Maybe more important in this case was the effect of fatigue of everybody contributing in the patient treatment. We worked for the fourth time together that week and patient was presented in the middle of the night at 3 AM in the hospital around the known window of circadian lows. A period during night hours in which effects of fatigue are most. Speed of thinking, effectivity, thinking of new and other options is highly reduced due to tiredness. Personally looking back, also the fact that it was my last nightshift in a week of four in total there was also a role in this case best described as “get there -itis”. Knowing that you’re almost there, at the end of a working period reduces your cognitive abilities.The fact that we worked for the fourth nightshift together with the same team also introduced a term that is called “group think”. If the first person mentions a possible diagnosis or option in the treatment plan; it is more difficult for others to keep their minds open for other, maybe more likely optional diagnosis.Looking back at the patient case in an emergency ward there’s always the question: “What if me miss this or that awful diagnosis in the middle of the night”. In hindsight I could have less aggressively ask for imaging when the patient was presented at our ward. But given the late hour of the night and because of communication that directed me into a certain likely diagnosis I choose to follow this path. Now it seemed too aggressive to act like this, given the fact that “atypical chest pain” – with no further clinical follow up necessary, was our final diagnosis. However the leukocyte number of 17.3 is still unexplainable!I found out a day or two later that this patient was known with a personality disorder type B (theatrical personality) could this be more explanatory in the patients presentation that night? The already mentioned circumstances made it that I wasn’t so aware of this medical history fact at the moment of treatment.

Supplement 1: Laboratory findings



9.

Benign bone findings in oncologic patients mimicking metastases

Lorenzo Alonso-Carrión1, Pedro Gutiérrez-Chacón2, Guillermo Ojeda-Burgos3

1Servicio de Oncología Médica, Hospital Clínico de Málaga, Servicio Andaluz de Salud2Servicio de Radiodiagnóstico, Hospital Clínico de Málaga, Servicio Andaluz de Salud3Servicio de Medicina Interna, Hospital Clínico de Málaga, Servicio Andaluz de Salud

Learning objectives: To describe some benign bone lesions detected during the follow-up of patients with a diagnosis of cancer that can be misdiagnosed as bone metastases.

Supplement 2: ECG

4. Hemangioma 6. Abscess over prosthesis5. Osteomyelitis

1. Sacral Tarlov′s cyst 2. Paget′ disease 3. Enchondroma

Figure 1:



7. Forestiere′s disease 8. Fibrous dysplasia

9. Stress fracture 10. Post-radiotherapy fracture 11. Brown tumor

Figure 2:

Case information: All patients had a diagnosis of cancer and a concomitant benign bone lesion. The details about the cases are as follows: (See Figures) 1. Tarlov’s cyst and lung cancer/ 2. Paget’s disease in prostate cancer/ 3. Enchondroma and liposarcoma/ 4. Hemangioma in breast cancer/ 5. Osteomyelitis and breast cancer/ 6. abscess over hip prosthesis in breast cancer/ 7. Forestiere’s disease and colon cancer/ 8. Fibrous dysplasia in colon cancer/ 9. Sacral stress fracture and breast cancer/ 10. Sacral fracture after pelvic radiotherapy/ 11. Parathyroid carcinoma and hyperparathyroidism: brown tumorDiscussion: At least one third of patients with cancer will develop bone metastases. This situation confers a worse prognosis and also a change of treatment. Furthermore, non-malignant bone lesions are detected quite often in oncologic patients and they should be taken into account in order to avoid a misdiagnosis of bone metastases.

10.

Bias Created by the Lure of an Interesting Diagnosis

Rose Mabwa, Karen Cosby, MDRush Medical School, Chicago IL

Learning Objectives:1. Recognize that “interesting cases” may create risk of misdiagnosis.2. It is important to establish objective facts that characterize a case. Words and descriptors may bias physicians towards (or away) from

specific diagnosis.3. “Diagnosis momentum” is a powerful draw in academic centers where clinicians may influence one another.

Case Description: A 55 year old woman presented with “feeling feverish” and complained of severe fatigue and myalgias. She had recently returned from a trip to Kenya. Her physician treated her presumptively for malaria. Despite compliance with her treatment, her symptoms worsened and progressed to include nausea and vomiting, eventually requiring admission for dehydration. A workup was unrevealing of the cause, and included malaria preps (negative times 3), influenza cultures, and hepatitis serology. She was treated presumptively for typhoid with levofloxacin. Despite that, she failed to improve and returned again to the hospital, where additional evaluation was done for CMV, EBV, and HIV viruses, as well as collagen vascular disease. She was transferred to a tertiary care center where she underwent a liver biopsy, and additional testing for tropical disease. When that failed she eventually went to her primary care doctor who recognized that her symptoms began before her travel, and noted thyromegaly. A simple bedside screen for thyroid revealed the actual diagnosis to be hyperthyroidism. The diagnosis took 2 months and 2 hospitalizations to establish.Discussion: There is a lure of the interesting case that may blind clinicians to what is real. In this case, clinicians focused on the history of “feeling feverish” and travel to Kenya and concentrated their evaluation on tropical illness, despite the fact that the patient never had a docu-mented fever. Thyromegaly was not noted even though she was examined by more than 30 doctors, including 9 specialty consultations. Was this phenomenon due to the momentum created by numerous clinicians pursuing a more interesting diagnosis?



11.

Volvulus: The silent killer

Drs. M. Wiggelinkhuizen, resident in pediatrics.Erasmus MC – Sophia, Dr. Molewaterplein 60, 3015 GJ Rotterdam, The Netherlands.

Learning objectives: – Volvulus is a silent killer: children can get suddenly severely ill. – When a child has had abdominal pathology in the past, always think about the diagnosis of volvulus when abdominal complaints do

occur. – Serum lactate can give a clue about the severity of the clinical condition. – Do not let ‘group reassurance’ omit your ‘gut feeling’ that something is wrong.

Case information: A boy, 6 years old, with thoracoscopic correction of diaphragmatic herniation and constipation problems in the past, presented in the night at the emergency department with sudden onset of abdominal pain: continuously mild pain, with intermittently severe colic pain. Psychical examination showed a boy with pale face, cold hands, inflated, non tender and souple belly, with normal bowel sounds and hypersonore percussion. Intermittently he was moving because of severe pain (Table 1). Blood test showed low infection parameters. Bloodgas and serum lactate were not measured. Ultrasound was difficult to interpretate as colon was dilated by air. In combi-nation with pathologic bowel wall thickening, suspicion of ileus was risen. X-thorax showed no recurrent diaphragmatic herniation. X-ray of abdomen showed complete dilated colon (7cm), till sigmoid, without different caliber. With working diagnosis (pseudo)- obstruction of colon, patient was admitted for observation, with rectum canula to releave intracolonic air. This was not effective. Patient remained inter-mittently in pain. In between painful moments, he did still walked by himself to the toilet. As his condition did not improve in the next 4 hours, patient was transmitted to an Academic Hospital. During transport his clinical situation deteriorated and resuscitation was started. After arrival in the hospital abdominal surgery was performed. His colon was ischaemic with bowel torsion. Diagnosis of volvulus was made. The boy died the next day…Discussion: Volvulus is often related with prior surgery. Correction of diaphragmatic hernia in the past must alert the doctor in charge the think about a volvulus.In patiënts with volvulus, clinical symptoms can be mild, until septic shock results from the introduction of toxins from gangrenous colonic loops. Serum lactate levels can be used to get an indication of the severity of the clinical condition1.In this case, multiple medical doctors were involved. Most of them were worried about the patient, although there was no definite diagnosis. Unfortunately, the clinical appearance of the boy –before septic shock occurred - made all the doctors reassure each other. So: be aware of ‘crowd reassurance’.Reference:1Aydin B, Ozban M, Serinken M, Kaptanoglu B, Demirkan NC, Aydin C.The place of D-dimer and L-lactate levels in the early diagnosis of acute mesenteric ischemia. Bratisl Lek Listy. 2015;116(5):343–50.

12.

A deadly case of melena in an elderly man

M. Kusajima, S. Matsuzaka, Y. SerizawaDepartment of General Internal Medicine, Teine Keijinkai Hospital, Sapporo, Japan

Learning objectives: To include surgical complications in the differential diagnosis of apparent medical conditions. To describe the concept of anchoring and availability heuristics.

Table 1: Vital signs at admission

Saturation 99%Heart rate 120/minBlood pressure 101/64 mmHgTemperature 37,4 degrees CelsiusCentral capillary refill < 2 secondsCold hands and feet



Case information: A 79-year-old man with history of two endovascular aortic repairs, second one performed 2-years prior, presented with slight fever, fatigue, and melena. His hemoglobin level was 7.2 mg/dL. The initial diagnosis was gastrointestinal bleeding probably associated with long term aspirin use.We performed a gastroesophageal endoscopy that revealed a duodenal ulcer stage A1 with coagulated blood causing the patient’s anemia. He was prescribed a proton pump inhibitor and discharged to home.However, two days after discharge the patient was brought back to the hospital in cardiopulmonary arrest. His hemoglobin level was 1.2 mg/dL. Despite resuscitation attempts, he died. Post-mortem imaging revealed a large endoleak from the abdominal aortic stent.Discussion: This is a typical case of premature closure or “anchoring heuristics”. In retrospect, we did not consider surgical complications because the last intervention had been 2 years prior and he was not complaining of abdominal pain. His initial history fit the diagnosis of medication-induced PID, and once the endoscopy confirmed an ulcer, the team stopped further workup: We “fell in love with our first puppy.” It may also be viewed as an example of “availability heuristics” for internist, since the patient fit the very common pattern of “GI bleed.” We failed to consider a broad differential diagnosis that included the life-threatening complications of an aorta-intestinal fistula or stent endoleak. In this patient, imaging (either CT or ultrasound) to confirm the integrity of the aorta could have saved his life.

13.

Nontoxic appearance masks severe infection

Masaji Saijo1, Toshiaki Wakai2, Dongkyung Seo1, Urara Nakagawa1, Dongje Seo3, Yasushi Tanabe1

1Sapporo Tokushukai Hospital, Sapporo, Japan2Ohasa Clinic, Ebetsu, Japan3Dankook University College of Medicine, Cheonan, Republic of Korea

Learning objectives: The classic triad of acute bacterial meningitis consists of fever, nuchal rigidity, and a change in mental status. However, one or more of the classic findings are absent in many patients with bacterial meningitis, and general appearance may not be toxic.Case information: 82-year-old female with a history of cervical spondylosis and lung carcinoma metastasizing to right iliac bone was brought to the Emergency Department of Sapporo Tokushukai Hospital for 2 days of worsening neck pain. On arrival, she was found to have nuchal rigidity with well general appearance, alert mental status and stable vital signs. Her neck pain was tentatively diagnosed as an exacerbation of cervical spondylosis. However, 12 hours after arrival, 1 set of blood cultures drawn on arrival showed gram-positive chain, which prompted her to lumbar puncture (LP). The cerebrospinal fluid (CSF) revealed high neutrophil-dominant white blood cells. Carcinomatous meningitis was suspected and antimicrobials were held due to her nontoxic appearance, alert mental status and stable vital signs. 14 hours after arrival, she was mildly disoriented, followed by immediate empiric antimicrobials. Retropharyngeal abscess and diskitis were found by neck CT and MRI, which were improved by aggressive intravenous antimicrobials.Discussion: The clinical features of acute bacterial meningitis usually develop over 24 to 48 hours and prompt empiric antimicrobials therapy is crucial. All of the three classic features are present in only 44% and nuchal rigidity is the most specific sign among them (Positive likeli-hood ratio is 1.3). In this case, however, because of the patient’s stability and nontoxic appearance, LP may have been delayed even with the presence of nuchal rigidity at initial evaluation, furthermore, antimicrobial therapy was hesitant to be initiated despite CSF result implying bacterial meningitis, due to faulty perception.

14.

Don’t judge a book by its cover - Psychotic symptoms are deceptive!

Dongkyung Seo1, Toshiaki Wakai2, Masaji Saijo1, Urara Nakagawa1, Dongje Seo3, Yasushi Tanabe1

1Sapporo Tokushukai Hospital, Sapporo, Japan2Ohasa Clinic, Ebetsu, Japan3Dankook University College of Medicine, Cheonan, Republic of Korea

Learning objectives: Medical clearance, excluding physical illnesses, is essential before diagnosing mental illnesses when newly developed psychotic symptoms are confronted.Case information: A 28-year-old previously healthy female was involuntarily hospitalized to psychiatric hospital for newly developed psy-chotic symptoms, followed by transfer to Sapporo Tokushukai Hospital for fever and electrolytes imbalances. 1 day prior to admission, she suddenly revealed disorganized speech while working and was brought back to home with her mother. Subsequently, she was agitated, left her home alone, rang doorbells of neighboring houses and was arrested by police officers. 15 hours prior to admission, she was involuntarily hospitalized to psychiatric hospital. Acute onset of schizophrenia was tentatively diagnosed initially, therefore risperidone and haloperi-dol were given. 2 hours prior to admission, her body temperature started to elevate and lab data on admission revealed electrolytes imbal-ances, which prompted her to transfer to Sapporo Tokushukai Hospital. On arrival, she was stuporous, disoriented, febrile, and tachycardic.



Cerebrospinal fluid by lumbar puncture revealed high lymphocyte-dominant white blood cells. Viral meningitis or meningoencephalitis were suspected, and empiric antiviral and antimicrobials were initiated. On hospital day 4, her mental status did not improve and several series of seizures occurred. During the evaluation, she had 13 seconds of pause of heart beat in monitor, which suggested sick sinus syndrome. She was transferred to tertiary hospital for cardiology consultation.Discussion: In this case, psychiatric disorder was tentatively diagnosed because she presented with psychotic symptoms alone including dis-organized speech and altered mental status (AMS). Medical diagnoses were missed in 2.8% of patients who were admitted to psychiatric units due to AMS. (Reeves, 2010) It is crucial for all physicians to proceed to exclude physical illnesses when newly developed psychotic symptoms are confronted until proven otherwise without premature closure.

15.

Mastering the art of conversation in Pediatrics – a key in reducing diagnostic errors

Stefana Cristina Alexoaie1, Diana Veronica Costache2, Traian Mihaescu2

1“Sfanta Maria” Emergency Hospital for Children, Iasi, Romania2Clinic of Pulmonary Disease, Iasi, Romania

Learning objectives: Diagnostic errors in Pediatrics represent a branch which is less explored and accepted in our country. Mistakes are not easy to accept by anyone, and doctors make no exception. In order to carry out his activity in optimum conditions, a doctor must be versed not only in Pediatrics pathology, but also in child psychology. The main causes for diagnostic errors in Pediatrics are the wrong information received from the careers and the patient himself.For small children, communication is difficult, given that they do not know all the necessary words, which prevents them from describing what is bothering them. Things are different for older children, which have a tendency to hide certain aspects about their life, but these exact details may cause further harm to their health.Case information: The paper shows the cases of two children which describe perfectly the mentioned typologies. The first case is that of a two years old boy, known for an unique ventricle and epilepsy. At first he was diagnosed with sleepiness due to treatment with phenobarbital, but later on it was found that he suffered from cerebral thrombosis. The second case is that of a 12-years old girl diagnosed with epilepsy at 10 years old, undergoing treatment with divalproex sodium, who presented to the hospital for sleepiness, dizziness and headache. At the beginning of the anamnesis the little patient declared that she didn’t take her treatment as it was prescribed. The toxicological testing of the blood revealed that indeed she took the clonazepam. After a long talk, the patient confessed a self-administration of pills, prior to her epilepsy diagnosis.Discussion: The quality of the information gathered by the physician during his investigations is tightly connected to the communication abilities with the young patient, the observation awareness and the promptness showcased during the examination. The first case underlines the importance of good observational skills as the second case, the necessity of good communication abilities. Both aspects are vitals in the activity of every pediatrician.

16.

A physiotherapist falls prey to diagnostic momentum

Suzanne AlstonPhysical Therapy Program, College of Professional Studies, Northeastern University, Boston, MA, USA

Learning objectives: The report “Improving Diagnosis in Health Care” recommends effective teamwork in the diagnostic process.1 Errors in diagnosis are perpetuated when team members fail to question the original diagnosis.Case information: A 49-year-old woman presented to a hand surgeon with pain on the dorsal lateral aspect of the wrist 7 weeks following a fall on ice. A triquetral fracture was diagnosed with x-rays. The wrist was splinted for 4 weeks. Pain persisted, and an MRI was ordered to rule out occult scaphoid fracture (Figure 1). The Physician Assistant reported the findings of “partial thickness split tear of the extensor carpi ulnaris tendon, small avulsion fracture of the pisiform, and synovitis.” The patient was referred to hand therapy. One year later, swelling persisted with 10% loss of wrist range of motion. The patient requested referral from her primary care physician to physiotherapy for joint mobilization. Unfortunately, the forceful joint mobilizations accentuated erosive damage of the carpal bones. The patient subsequently lost 80% of wrist range of motion. The diagnosis was rheumatoid arthritis (RA). The radiologist’s MRI report included findings of “a large bony erosion of the capitate, suspicious for inflammatory arthropathy.” Those details were not shared with the patient or therapists. Neither therapist requested the radiologist’s report.Discussion: Fractures of carpal bones are common following trauma. It seems reasonable to call off the search once a fracture is found. RA affects 1% of the population, striking most in the third to sixth decades. Diagnostic momentum influenced the physiotherapist. This case illus-trates the importance of considering alternative diagnoses and accessing the radiologist’s report (rather than relying on the referral prescription).Reference:1. Institute of Medicine. Improving Diagnosis in Health Care, National Academies of Sciences, Engineering and Medicine, 2015.



17.

Diagnostic errors in an alcoholic patient; A tale of three emergency departments

Suzette R. Clarke, Samim S. Jafri, Laura E. Garcia (Mentor), and James F. Hanley (Mentor)The University of Texas Rio Grande Valley, Valley Baptist Medical Center, Internal Medicine Residency Program, Harlingen, Texas, USA

Learning objectives:a. Recognition that emergency departments are a “hot zone” for diagnostic errors.b. In alcoholic patients, there is risk for visceral and availability bias leading to premature closure.c. Diagnostic momentum can persist over long distances and different organizations.

Case information: 57-year-old Hispanic male with a history of alcohol abuse presented to emergency department (ED) A with episodes of hematemesis and generalized pain. A limited evaluation demonstrated BP 150/99, pulse 120, and hemoglobin 7.1g/dL. With a presumed diagnosis of GI bleeding and unavailable ICU bed, he was transferred 200 miles to ED B. The second ED B physician performed a cursory evaluation, confirmed anemia, and arranged for an EGD; findings included a Mallory-Weiss tear. He was prescribed omeprazole and dis-charged home. In ED A and ED B isolated elevated alkaline phosphatase (792 – 937 IU/L) was noted in the setting of normal ALT/AST that was unaddressed. Prevailing on a physician friend, he was re-evaluated in ED C. At this time, abdominal CT revealed bilateral hydronephrosis, extensive lymphadenopathy, and osteoblastic bone metastases with near cord compression. Metastatic prostate cancer was diagnosed and he was emergently managed.Discussion: Croskerry and others have described the ED as the laboratory for diagnostic errors. The hyperkinetic environment is driven to make rapid diagnoses and dispositions. Physicians in this environment often have visceral and availability biases, which lead to premature closure and a desire to rapidly transition these patients.In this case, the initial disposition was inappropriate but the diagnosis momentum persisted with inadequate assessment and an unac-ceptable cascade of events at ED B. Critical laboratory data was available but unaddressed at both sites. While an understanding of diagnostic errors and individual responsibilities are essential, major improvements are unlikely to occur without a re-engineering of the ED environment.

18.

A diagnostic stalemate

Segerson T, Giles J, Akhtar J, Schillo GUniversity of Pittsburgh Medical Center

Learning objectives: Failure to suspect a disease in patients with atypical presentations is the commonest cause of diagnostic error. Reliance on the presence or absence of clinical signs or results of diagnostic testing alone may lead to a missed diagnosis. Diagnostic stalemate result-ing from this may lead to diagnostic delay and treatment.Case information: On 09/17/2015 a 64 year-old woman with a history of hypertension and 45 pack year smoking history presented to the emer-gency with chronic right lower extremity, pain behind her knee and back pain that was worse with walking and relieved with sitting. She was seen by orthopedics in the past who ruled out lumbar stenosis. She also had lower extremity arterial duplexes performed which were within

Figure 1:



normal limits. She has had difficulty walking long distances for many years, however it has gotten worse over the past few months. She is now not able to walk more than 20 feet without having to sit down. She also reports posterior left thigh muscle cramping and numbness that has developed over the past week. She had seen by several physicians including an orthopedist and received several epidural injections for symptom control, which have been ineffective for her pain. She was now scheduled to see a neuromuscular specialist in 2 days,On physical examination her vitals were all normal The chest was clear to auscultation. Heart sounds were regular and not muffled. The abdomen was without any masses. There was no bruit. A vascular examination showed her to have strong and symmetrical pulses. A neuro-logical examination did not show her to have any deficit both muscular or sensory. The reflexes were normal. Skin examination did not show mottling.A diagnostic test was done.This was a CT angiography abdominal aorta with lower extremity runoff with and without contrast.Impression: There is near complete occlusion of the infrarenal abdominal aorta secondary to thrombus. Both common and external iliac arter-ies are patent without evidence of thrombus. Both internal iliac arteries are patent. The common femoral arteries and origins of the superficial femoral and profunda femoral arteries are patent. Celiac axis and superior mesenteric arteries are widely patent. Single bilateral renal arteries are patent. The inferior mesenteric artery origin is patent.09/17/2015. She was taken to the operating room where she had aortogram and pelvic angiogram which showed a focal aortic occlusion in the mid aorta. She underwent recanalization of aortic occlusion with aortic angioplasty and stenting. Her symptoms rapidly improved and she was discharged home.03/13/2014: An office note from one of her treating physicians read: This is a young lady with a pretty classic history. She walks 10 minutes, has serious pain in her anterior tibial area and posteriorly behind the knee and into the thigh. Sits down for 10 minutes, feels better and is able to go about. If she would try to get into a car, she says the knee area hurts a lot. She is status post ACL reconstruction on the left side by Dr. RW. RW saw her, said everything looked okay and injected her knee with no help. Was sent to Dr. BD and it actually sounds like spinal claudica-tion, but her MRI was totally unremarkable. Again, the history, her exam is benign. Knee exam is benign. Hip exam is benign. No limp. I do not feel any areas of coolness, and I can feel pulses in her feet. We have to get the arterial Doppler studies. If they are negative, what I expect they might be, I am not sure where I would go with it after that.November 13, 2013: MR spine lumbar without contrast: Clinical history: 62-year-old female with low back pain and right leg pain brought on by walking, improved by rest.Moderate facet arthropathy at L3/L4 with fluid in the left facet joint, associated paraspinal edema and increased T2 signal in the L4 pedicles compatible with chronic strain injury. Mild facet arthropathy at L1/L2, L4/L5 and L5/S1March 17 2014: An arterial doppler was read as: Duplex of the common femoral arteries demonstrates triphasic Doppler waveforms bilaterally. ABIs are > 1.0 bilaterally with toe pressures of 91 on the right and 131 on the left, indicating normal perfusion at rest. Waveforms are blunted bilaterally.Discussion: The diagnostic uncertainty in our case was solved by believing in the clinical impression and following it up with a better test. “If the clinical probability of a disease is high and initial tests are negative then it’s often a good idea to repeat with a high yield test”.1

Reference:1. Jawaid Akhtar, personal communication, June 6, 2009


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