reducing diagnostic error tim shoen, md campaign for quality october 17, 2014
TRANSCRIPT
Reducing Diagnostic Error
Tim Shoen, MD
Campaign for Quality
October 17, 2014
Disclosure
No financial interest to disclose
Thanks to Mark Graber, MD, President, SIDM.
Sue Sheridan
Wall Street Journal
The Biggest Mistake Doctors Make
Misdiagnoses are Harmful and Costly
But they're often preventable
Laura Landro
November 17, 2013
Patient Safety Awareness 2014
Creating a world where patients and those that care for them are free from harm.
www.npsf.org
Society to Improve Diagnosis in Medicine
We envision a world where diagnosis is accurate, timely, and efficient.
www.improvediagnosis.org
Gregory House, MD
Objectives
• Review Incidence
• Contribution of Cognitive and System factors
• Improvement Efforts
Diagnosis
The satisfaction of solving The Riddle…is every doctor’s measure of his own abilities; it is the most important ingredient in his professional self-image.
Dr. Sherwin Nuland
How We Die 1994
Human Error
• Skill Based – error rate 1:1000
• Rule Based– error rate 1:100
• Knowledge Based– error rate 1:2
Preventable Harm
ErrorAdvers
e
Event
Diagnostic Error
• Delayed Diagnosis
• Missed Diagnosis
• Wrong Diagnosis
Expert A. Elstein: 10-15%
Patient Survey
One third relate a Dx error affected themselves, family
SecondReviews
Radiology and Pathology: 2-5% cancers missed
Look backs 30% of subarachnoid hemorrhage misdiagnosed; 39% of dissecting AAA delayed diagnosis; A third of neurological diagnoses wrong or likely wrong
Autopsy Major unexpected discrepancies that would have changed the management are found in 10-20%
Estimates of Dx Error Rate
Estimates Diagnostic Error Rate
Trauma 8% of pts have missed injuries
General ER .6% of 5000 admitted pts at Wayne State
MI 2-3% of pts sent home have an MI; 90% of pts admitted don’t have an MI or ACS
Liability 47% claims high severity cases alleged Dx related
OutpatientClinic
1:20 patients experience dx error each year
Diagnostic Errors
• Are common and cause enormous harm
• Estimates 40,000-80,000 annual deaths
• Overlooked with emphasis on system improvement
• Measurement tools lacking
Etiology of Diagnostic Error
Both System and Cognitive Errors
46%
Cognitive Error Only28%
System Error Only19%
No Fault Error Only7%
Cognitive Errors: 320
Faulty Synthesis 83 %
Faulty Knowledge
3 %
Faulty Data Gathering 14 %
Diagnostic Errors
• Are common and cause enormous harm
• Most errors involve both system and cognitive components.
• Cognitive errors most often reflect problems using intuition
Cognitive Psychology
Brain
Hard wiringAmbient conditions/ContextTask characteristicsAge and ExperienceAffective stateGenderPersonality
EducationTrainingCritical thinkingLogical competenceRationalityFeedbackIntellectual ability
Pattern Recognition
Repetition
Executiveoverride
Dysrationaliaoverride Calibration Diagnosis
PatientPresentation
PatternProcessor
RECOGNIZED
NOTRECOGNIZED
1
2
Dual Process Model of Clinical Reasoning
Heuristic and Bias
• Confirmation Bias
• Availability
• Anchoring
COGNITIVE ERRORS Most common:
• Premature closure (39)• Faulty context generation (26)• Faulty perception (25)• Failed heuristic (23)
Problems Solutions
• Faulty context• Premature closure• Failed heuristic• Framing errors
• Consider the opposite• Crystal ball experience• Reflection• Be comprehensive• Learn the antidotes
How can we make diagnosis more reliable ?
DX Reasoning
The PROBLEM: COMPLEXITY
The SOLUTION:NOT training; NOT redesign
A Checklist
The B-17, and its checklist, flew the next 1.8 million miles without an accident. The military obtained over 13,000, and the B-17 was the workhorse of the Allied air force in
World War II.
13,000 known diseases, syndromes, injuries
4,000 possible tests
6,000 medications, treatments, and surgeries
The average limits of human working memory:7 discrete items
Complexity in Medicine
The Surgical Checklist• WHO sponsored study in 8 countries• 19 item checklist:
– Sign in + Time out + sign out• Evaluated in 3733 operations:• Results:
– Major complications fell from 11 to 7%– Death rate fell from 1.5 to 0.7% (p = 0.003)
Haynes et al. NEJM 360: 491-9, 2009
A Checklist for Diagnosis
Obtain YOUR OWN history Perform a focused, purposeful exam Take a “Diagnostic Time Out”
Was I comprehensive ? Did I consider the inherent shortcomings of using my
intuition (heuristics) ? Was my judgment affected by bias ? Do I need to make the diagnosis now or can it wait ? What’s the worst case scenario?
Embark on the plan, but ENSURE FOLLOW-UP & FEEDBACK
Structured ReflectionV ascularI nfections & intoxicationsT rauma & toxinsA uto-immuneM etabolicI diopathic & iatrogenicN eoplasticC ongenitalC onversion (psychiatric)D egenerativeE ndocrine
Possible Solutions
• National Agenda
• Research
• Health IT
• Clinical Reasoning Education
Summary
• Diagnosis errors are common and harmful
• High quality healthcare requires high quality diagnosis
• Diagnostic errors are costly• Healthcare Organizations are well
positioned to lead efforts to reducing these errors
Case Studies
• Maine Medical Center– Physician Reporting
• SoCal Kaiser Permanente– Electronic Records to Trace Diagnostic
Error
Reference
Reference
