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Reducing Diagnostic Error

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

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Reducing Diagnostic Error

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  1. Reducing Diagnostic Error Tim Shoen, MD Campaign for Quality October 17, 2014

  2. Disclosure No financial interest to disclose Thanks to Mark Graber, MD, President, SIDM.

  3. Sue Sheridan

  4. Wall Street Journal The Biggest Mistake Doctors Make Misdiagnoses are Harmful and Costly But they're often preventable Laura Landro November 17, 2013

  5. Patient Safety Awareness 2014 Creating a world where patients and those that care for them are free from harm. www.npsf.org

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

  7. Gregory House, MD

  8. Objectives • Review Incidence • Contribution of Cognitive and System factors • Improvement Efforts

  9. 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

  10. Human Error • Skill Based • error rate 1:1000 • Rule Based • error rate 1:100 • Knowledge Based • error rate 1:2

  11. Preventable Harm

  12. Diagnostic Error • Delayed Diagnosis • Missed Diagnosis • Wrong Diagnosis

  13. Estimates of Dx Error Rate

  14. Estimates Diagnostic Error Rate

  15. Diagnostic Errors • Are common and cause enormous harm • Estimates 40,000-80,000 annual deaths • Overlooked with emphasis on system improvement • Measurement tools lacking

  16. Cognitive Errors: 320 Faulty Knowledge 3 % Faulty Data Gathering 14 % Faulty Synthesis 83 %

  17. Diagnostic Errors • Are common and cause enormous harm • Most errors involve both system and cognitive components. • Cognitive errors most often reflect problems using intuition

  18. Cognitive Psychology

  19. Brain

  20. Hard wiring Ambient conditions/Context Task characteristics Age and Experience Affective state Gender Personality Dual Process Model of Clinical Reasoning 1 RECOGNIZED Pattern Recognition Patient Presentation Pattern Processor Executive override Dysrationalia override Calibration Diagnosis Repetition 2 NOT RECOGNIZED Education Training Critical thinking Logical competence Rationality Feedback Intellectual ability

  21. Heuristic and Bias • Confirmation Bias • Availability • Anchoring

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

  23. Problems Solutions How can we make diagnosis more reliable ? Faulty context Premature closure Failed heuristic Framing errors • Consider the opposite • Crystal ball experience • Reflection • Be comprehensive • Learn the antidotes

  24. DX Reasoning

  25. 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.

  26. Complexity in Medicine 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

  27. 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

  28. 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

  29. Structured Reflection V ascular I nfections & intoxications T rauma & toxins A uto-immune M etabolic I diopathic & iatrogenic N eoplastic C ongenital C onversion (psychiatric) D egenerative E ndocrine

  30. Possible Solutions • National Agenda • Research • Health IT • Clinical Reasoning Education

  31. 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

  32. Case Studies • Maine Medical Center • Physician Reporting • SoCal Kaiser Permanente • Electronic Records to Trace Diagnostic Error

  33. Reference

  34. Reference

  35. Questions? Tim Shoen, MD shoen7754@aol.com Subject: Dx Error

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