1. Tim Munzing, MD & Diane Jerng, MD KP Orange County

2.  Attendees will learn to: ◦ Discuss aspects of physician thought patterns that contribute to medical errors ◦ List the most common cognitive errors in patient care ◦ Describe physician error patterns including diagnosis momentum and commission bias ◦ Improve patient outcomes by avoiding common contributors to medical errors

3.  “How Doctors Think” – Jerome Groopman, 2007  To Err is Human: Building A Safer Health System, Institute of Medicine, 1999  Crossing the Quality Chasm: A New Health System for the 21st Century, IOM, 2001  Leadership Guide to Patient Safety, Institute of Healthcare Improvement. 2006

4. Review paper handout – Leading Causes of Death In US, 1999 CDC and IOM stats Rank the causes of death from most common (#1) to least common (#10)

5.  1) Heart Disease 725,192  2) Cancer 549,838  3) Stroke/CVA124,181  4) Unintentional Injury97,860  5) Medical Errors (44,000 – 98,000)  6) Diabetes68,399  7) Influenza, PNA63,730  8) Alzheimer’s44,536  9) Nephritis/Nephrotic 33,525  10) Septicemia30,680

6.  15 million incidents of medical harm each year (IHI data)  181,000 severe injuries attributable to medical negligence - 2003 (CBO)  Between 44,000 and 98,000 Americans die annually in US hospitals due to preventable medical errors (IOM, 1999)  99,000 patients die annually of hospital- acquired infections (AHRQ, 2009)  7,000 annually die from medical errors (Kaiser Family Foundation)

8.  20 y.o. woman with abd pain, n/v, given antacids  Continued sx with decreased appetite, forced self to eat, felt worse and would then regurgitate  PMD suspected bulimia. Referred to psych, dx w/ anorexia w/ bulimia  Over next few years seen by several physicians and continued wth PMD devoted to pts with eating disorders  Also intermittently seen by endocrinology, orthopedics, hematology, ID, psychiatry and psychology. Tried four different antidepressants and talk therapy  Registered dietician monitored pt’s diet and calorie counts. Reported consuming adequate calories but had persistent wt loss. ? if patient was correctly reporting, falsifying reports?  Eventually seen by a GI physician years later and diagnosed with celiac sprue.

10.  Medication Errors  Surgical Errors  Diagnostic Errors  Equipment Failure  Nosocomial Infections  Blood Transfusion Injuries  Errors of Commission and Omission

11.  Involves missed or delayed diagnoses  Causes most morbidity & mortality 40,000 – 80,000 deaths annually (JAMA)  Most frequent cause of lawsuits

12. Participant Activity : Medical Error Exercise Write briefly about a case involving a missed, nearly missed, or delayed diagnosis that you were involved with or witnessed. Be as specific as you can. What factors do you think contributed to the event? We will hear from several of you.

13. Medical Decision Making and Cognitive Disposition to Respond Decisio n Making Ambient condition s Past Experienc e CDR’s Patient Factors Team Factors Affective State

14.  Majority is due to failure in thinking rather than technical skill  Misdiagnosis causing harm – 80% from cognitive errors  Providers ignore contradictory information  15% of all diagnoses are wrong

15.  Missing allergies when prescribing  Ignoring medication / medical problem interaction  Not considering medication – medication interactions  “Done-ing” abnormal labs/imaging/path/etc. without acting on them  Medication errors – wrong medication, dosage, route, site  Procedures – wrong patient, site, procedure..

16.  Anchoring ◦ Not considering multiple possible diagnoses ◦ Premature closure ◦ Assuming diagnosis by experts as correct ◦ Safeguard – include short diff dx  Availability ◦ Tendency to judge likelihood of an event based on recent experience ◦ Cherry pick signs and symptoms – confirmation bias – selectively excepting or ignoring information ◦ Rationalizes contradictory information

17.  Useful for many patients  Patient must be appropriate for guideline used  Difficult to use for patients with multiple or confusing symptoms  Representative Error ◦ Thinking guided by prototype ◦ Failure to consider possibilities that contradict prototype

18.  Can be helpful or harmful  First impressions  Open ended vs. close ended questions  Physicians interrupt < 18 seconds into visit  Limits information gathering

19.  Blurs ability to care for patient – positive or negative emotion  Harder to adjust diagnoses to correct ones  Negative Emotion ◦ Less time ◦ Quicker diagnoses ◦ Sicker patients may be less liked  Positive Emotion ◦ Under investigate ◦ Delay in diagnosis ◦ Tries to avoid uncomfortable procedures

20.  Insufficient history -inaccurate diagnoses and treatment  When patient’s history is cut off – often vital information is missed  Patient’s compliance improves when feeling heard and understood  Increase in cognitive errors  Decrease in communication  Symptoms minimized  Monotony

21.  “Patient with HTN and renal failure”  Accepting the “frame” may cause errors  “Frame” may be incorrect  Pay attention to conflicting data  “What is the worst thing that could be missed?”

22.  Patients who fit a negative stereotype (eg. Alcoholic, smoker, obese. etc.)  Physicians may ignore real diagnosis  Premature closure in thinking  Consider alternative diagnoses  (e.g.. Patients who drinks alcohol and develops liver failure – may not be related and may not be an alcoholic)

23.  Once diagnosis is fixed – in spite of insufficient evidence  Difficult to change diagnosis  Diagnosis passed on to other physicians  Expert – assumed to be correct  Focus on positive results and ignore other results  Be willing to question diagnoses

24.  Commission Bias – action vs. inaction  Satisfaction of the Search ◦ Stop investigation once a finding is found ◦ May miss actual diagnosis  Thinking Inside the Box ◦ Ignores possibility of rare diagnoses ◦ “What else could it be?”

25.  Focus on Clinical Outcomes Improvements and Patient Safety benefits from robust EHR  Medical Error Reduction  Examples to follow

27. Clinical Decision Support Patient Safety

30. Improved Outcomes - Order Sets

35. 1. Develop Cognitive Disposition to Respond Insight & Awareness 2. Consider Internal & External Factors 3. Consider Context Formation 4. Info Gathering: Prevalence 5. Info Gathering: Data Interpretation 6. Verification

36. Questions? Comments? Thank you!