Reducing Diagnostic Error

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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 - PowerPoint PPT Presentation


Diagnostic Errors in Medicine

Reducing Diagnostic ErrorTim Shoen, MDCampaign for QualityOctober 17, 2014DisclosureNo financial interest to disclose

Thanks to Mark Graber, MD, President, SIDM.Sue Sheridan

Wall Street JournalThe Biggest Mistake Doctors Make

Misdiagnoses are Harmful and CostlyBut they're often preventable

Laura LandroNovember 17, 2013Patient Safety Awareness 2014

Creating a world where patients and those that care for them are free from harm.www.npsf.org5

Society to Improve Diagnosis in Medicine

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

Gregory House, MD

ObjectivesReview Incidence

Contribution of Cognitive and System factors

Improvement Efforts

12DiagnosisThe satisfaction of solving The Riddleis every doctors measure of his own abilities; it is the most important ingredient in his professional self-image.

Dr. Sherwin NulandHow We Die 1994

Human ErrorSkill Based error rate 1:1000Rule Based error rate 1:100Knowledge Based error rate 1:2

Preventable Harm Diagnostic ErrorDelayed Diagnosis

Missed Diagnosis

Wrong DiagnosisExpertA. Elstein: 10-15%Patient SurveyOne third relate a Dx error affected themselves, familySecondReviewsRadiology and Pathology: 2-5% cancers missedLook backs30% of subarachnoid hemorrhage misdiagnosed; 39% of dissecting AAA delayed diagnosis; A third of neurological diagnoses wrong or likely wrongAutopsyMajor unexpected discrepancies that would have changed the management are found in 10-20%Estimates of Dx Error RateEstimates Diagnostic Error Rate Trauma8% of pts have missed injuriesGeneral ER.6% of 5000 admitted pts at Wayne StateMI2-3% of pts sent home have an MI; 90% of pts admitted dont have an MI or ACSLiability47% claims high severity cases alleged Dx relatedOutpatientClinic1:20 patients experience dx error each yearDiagnostic ErrorsAre common and cause enormous harm Estimates 40,000-80,000 annual deathsOverlooked with emphasis on system improvementMeasurement tools lacking



Cognitive Errors: 320Faulty Synthesis 83 %Faulty Knowledge 3 %Faulty Data Gathering 14 %21Diagnostic ErrorsAre common and cause enormous harmMost errors involve both system and cognitive components. Cognitive errors most often reflect problems using intuition22

Cognitive Psychology


Hard wiringAmbient conditions/ContextTask characteristicsAge and ExperienceAffective stateGenderPersonalityEducationTrainingCritical thinkingLogical competenceRationalityFeedbackIntellectual abilityPattern RecognitionRepetitionExecutiveoverrideDysrationaliaoverride


PatternProcessorRECOGNIZEDNOTRECOGNIZED12Dual Process Model of Clinical ReasoningHeuristic and BiasConfirmation Bias



COGNITIVE ERRORS Most common:Premature closure (39)Faulty context generation (26)Faulty perception (25)Failed heuristic (23)

29 Problems SolutionsFaulty contextPremature closureFailed heuristicFraming errorsConsider the oppositeCrystal ball experienceReflectionBe comprehensiveLearn the antidotes

How can we make diagnosis more reliable ?DX Reasoning


The SOLUTION:NOT training; NOT redesignA ChecklistThe 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, injuries4,000 possible tests6,000 medications, treatments, and surgeries

The average limits of human working memory:7 discrete itemsComplexity in MedicineThe Surgical ChecklistWHO sponsored study in 8 countries19 item checklist: Sign in + Time out + sign outEvaluated 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, 2009A Checklist for Diagnosis Obtain YOUR OWN history Perform a focused, purposeful exam Take a Diagnostic Time OutWas 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 ?Whats the worst case scenario? Embark on the plan, but ENSURE FOLLOW-UP & FEEDBACK35Structured ReflectionVascularInfections & intoxicationsTrauma & toxinsA uto-immuneM etabolicIdiopathic & iatrogenicN eoplasticC ongenitalC onversion (psychiatric)D egenerativeE ndocrine36Possible SolutionsNational Agenda


Health IT

Clinical Reasoning Education

SummaryDiagnosis errors are common and harmfulHigh quality healthcare requires high quality diagnosisDiagnostic errors are costlyHealthcare Organizations are well positioned to lead efforts to reducing these errors

Case StudiesMaine Medical CenterPhysician Reporting

SoCal Kaiser PermanenteElectronic Records to Trace Diagnostic ErrorReference


Questions?Tim Shoen,

Subject: Dx ErrorChart10.

Both System and Cognitive Errors46%Cognitive Error Only28%System Error Only19%No Fault Error Only7%Etiology of Diagnostic Error

Sheet1No Fault Only7%System Only19%Cognitive Only28%Both System AND Cognitive46%


Both System and Cognitive Errors46%Cognitive Error Only28%System Error Only19%No Fault Error Only7%Etiology of Diagnostic Error




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