The Canadian Medical Protective Association © CMPA 10/31/2017 Common Diagnostic Errors - Decreasing risk in your practice Shirley Lee MD, MHSc(Ed), FCFP (EM) Physician Advisor-Practice Improvement, CMPA McGill Family Medicine Refresher Course 2017 The Canadian Medical Protective Association © CMPA Faculty / Presenter Disclosure Faculty: Dr Shirley Lee Employee of: CMPA Relationships with commercial interests: Grants / Research Support: Speakers Bureau / Honoraria: Consulting Fees: Other: Conflict of Interest - I have no financial or professional affiliation with any organization that can be perceived as a conflict of interest in the context of this presentation. Copyright - Not to be distributed without written permission of CMPA. No audio recording, video recording, or photography is allowed without CMPA's permission. Information is for general educational purposes only and is not intended to provide specific professional medical or legal advice or constitute a “standard of care”. Media Asset Copyright - All non-CMPA audiovisual files are used with permission and for educational purposes only. All rights belong to the original owner as per license agreements – Thinkstock, YouTube and others as required. The Canadian Medical Protective Association © CMPA

Disclaimer Objectives Describe medical-legal risks associated 10/31/2017 Disclaimer Cases in this presentation are used for educational purposes only and are based on actual events. They have been de-identified and/or anonymized to protect privacy. Please do not photograph or disseminate this information. The Canadian Medical Protective Association © CMPA Objectives Describe medical-legal risks associated with diagnostic errors Name 3 common issues seen in CMPA cases involving diagnostic issues Identify 3 strategies for reducing your medical-legal risk with cases involving a challenging diagnosis The Canadian Medical Protective Association © CMPA

10/31/2017 Clinical issue + costs 10,209 Legal actions closed Diagnostic issues account for highest proportion of costs The Canadian Medical Protective Association © CMPA 25-year US malpractice claims analysis Diagnostic errors most frequent type (28.9%) Highest proportion of total payments (35.2%) [BMJ Qual Saf 2015;22:672-80] The Canadian Medical Protective Association © CMPA

Pathology/ Diagnostic Imaging 10/31/2017 Is diagnostic error more often associated with certain specialties? Frequency of diagnostic issues CMPA closed cases by specialty Pathology/ Diagnostic Imaging #1 Medical Specialties/ Pediatrics #1 Emergency Medicine #1 Surgical Specialties/Ob-Gyn #2 Family Medicine/ Psychiatry #1 Anesthesiology/ PM&R 6-14% of cases The Canadian Medical Protective Association © CMPA

Most diagnostic errors involve common conditions 10/31/2017 Most diagnostic errors involve common conditions [Myths and Facts About Diagnostic Errors 2013] The Canadian Medical Protective Association © CMPA Family Medicine Listen to BACH (Lung, Breast, Appendix, Colon, Heart) The Canadian Medical Protective Association © CMPA [Fam Pract Manag Jul 2012]

73% 14% 25% Psychiatry Process of care analysis of diagnostic errors 10/31/2017 Psychiatry Suicidality and deteriorating psychosis The Canadian Medical Protective Association © CMPA Process of care analysis of diagnostic errors Assessment and Testing, Management investigation processing and and follow-up interpretation 73% 14% 25% The Canadian Medical Protective Association © CMPA

Common Cognitive Biases 10/31/2017 Not just due to provider issues The Canadian Medical Protective Association © CMPA Anchoring Premature closure Search satisfaction Common Cognitive Biases Zebra retreat Bandwagon effect Attribution error Authority bias Availability bias The Canadian Medical Protective Association © CMPA

Have I ruled out the most serious diagnosis? 10/31/2017 Addressing cognitive pitfalls The Canadian Medical Protective Association © CMPA “What else could this be?” Cognitive forcing strategies Have I ruled out the most serious diagnosis? The Canadian Medical Protective Association Does something not fit? © CMPA Is there a cognitive bias?

In high-risk situations… 10/31/2017 In high-risk situations… Pause to reflect Take a diagnostic ‘time out’ The Canadian Medical Protective Association What else could this be? © CMPA Make sure the patient knows when and how to get back to you if necessary What would the courts say? The Canadian Medical Protective Association © CMPA

A normal, prudent practitioner of similar training and experience 10/31/2017 Standard of care A normal, prudent practitioner of similar training and experience The Canadian Medical Protective Association © CMPA Courts do not expect perfection “A doctor is not expected to be infallible, only to exercise reasonable care, skill and judgment in coming to a diagnosis. If this is done, the doctor will not be held liable even if the diagnosis is mistaken.” (Picard & Robertson) The Canadian Medical Protective Association © CMPA

Hindsight and hindsight bias 10/31/2017 Hindsight and hindsight bias BEFORE arriving at a final diagnosis The Canadian Medical Protective Association © CMPA The puzzle is solved, the final diagnosis is clear AFTER determining AFTER a delay in the final diagnosis making a diagnosis or a misdiagnosis CMPA experience Diagnostic delays/misdiagnosis Deficient history & general assessment The Canadian Medical Protective Association © CMPA

Vital signs important to review 10/31/2017 Failure to document pertinent history, physical findings, and rationale for DDx The Canadian Medical Protective Association © CMPA Vital signs important to review The Canadian Medical Protective Association © CMPA

Repeated presentations for same complaint 10/31/2017 In diagnostic delays with failure to obtain/ interpret vital signs 80% had unfavourable outcomes for the MD The Canadian Medical Protective Association © CMPA Repeated presentations for same complaint The Canadian Medical Protective Association © CMPA

Does a clinical algorithm/ guideline suggest testing? 10/31/2017 Failure to perform diagnostic tests or refer to a specialist Does a clinical algorithm/ guideline suggest testing? Does something not fit? Is this a return visit? The Canadian Medical Protective Association © CMPA Delay / failure to assess patient

Deficient assessments prevalent in CMPA cases 10/31/2017 Diagnosis – the 4 D’s: Deficient assessments prevalent in CMPA cases Diligence with vital signs, repeat visits, concerns from patients/staff Duty to follow up tests Document: assessment, discussion, DDx, discharge instructions The Canadian Medical Protective Association © CMPA Take home points Be aware of cognitive biases When patient does not respond to your treatment, ask “What else could it be?” Ensure reliable system to follow up investigations The Canadian Medical Protective Association © CMPA

10/31/2017 1-800-267-6522 @cmpamembers The Canadian Medical Protective Association © CMP©A2016 The Canadian Medical Protective Association