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.

Society to Improve Diagnosis in Medicine We envision a world where diagnosis is accurate, timely, and efficient.

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 Error Adverse Event

Diagnostic Error Delayed Diagnosis Missed Diagnosis Wrong Diagnosis

ExpertA. Elstein: 10-15% Patient Survey One third relate a Dx error affected themselves, family Second Reviews Radiology and Pathology: 2-5% cancers missed Look backs30% of subarachnoid hemorrhage misdiagnosed; 39% of dissecting AAA delayed diagnosis; A third of neurological diagnoses wrong or likely wrong AutopsyMajor unexpected discrepancies that would have changed the management are found in 10-20% Estimates of Dx Error Rate

Estimates Diagnostic Error Rate Trauma8% of pts have missed injuries General ER.6% of 5000 admitted pts at Wayne State MI2-3% of pts sent home have an MI; 90% of pts admitted don’t have an MI or ACS Liability47% claims high severity cases alleged Dx related Outpatient Clinic 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

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 wiring Ambient conditions/Context Task characteristics Age and Experience Affective state GenderPersonality EducationTraining Critical thinking Logical competence RationalityFeedback Intellectual ability Pattern Recognition Repetition Executive override Dysrationalia override CalibrationDiagnosis Patient Presentation Pattern Processor RECOGNIZED NOT RECOGNIZED 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 Reflection Vascular Infections & intoxications Trauma & toxins A uto-immune M etabolic Idiopathic & iatrogenic N eoplastic C ongenital C onversion (psychiatric) D egenerative E 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

Questions? Tim Shoen, MD Subject: Dx Error