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Mark L Graber MD FACP Senior Scientist, Patient Safety Portfolio, RTI International Professor Emeritus, Dept of Medicine, SUNY Stony Brook, NY [email protected]

NPSF Professional Learning Series presents:

November 16, 2011

The new kid on the patient safety block: Diagnostic Error in Medicine

Richard E. Anderson, M.D., F.A.C.P Chairman and Chief Executive Officer The Doctors Company

November 16, 2011 NPSF Professional Learning Series

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Participant Notification ACKNOWLEDGEMENT OF COMMERCIAL SUPPORT: There was no commercial support received for this CME activity.

CONTINUING EDUCATION Physicians: This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of the Institute for the Advancement of Human Behavior (IAHB) and the National Patient Safety Foundation (NSPF). The IAHB is accredited by the ACCME to provide continuing medical education for physicians. AMA PRA Statement: The IAHB designates this educational activity for a maximum of 1 AMA PRA Category 1 Credit(s)™ Physicians should only claim credit commensurate with the extent of their participation in the activity. Nurses: IAHB is an approved provider of continuing nursing education by the Utah Nurses Association, an accredited Approver by the American Nurses Credentialing Center’s Commission on Accreditation. Provider Code P09-03. This course is co-provided by IAHB and the National Patient Safety Foundation. Maximum of 1 contact hour. Approved status as a provider refers only to its continuing education activities and does not imply UNA or ANCC Commission on Accreditation endorsement of any commercial products. Pharmacists:

Amedco is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. 1

contact hour. UAN: 0453-9999-11-046-L05-P (K)


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All faculty/speakers, planners, abstract reviewers, moderators, authors, co-authors and administrative staff participating in the continuing medical education programs jointly sponsored by IAHB are expected to disclose to the program audience any/all relevant financial relationships related to the content of their presentation(s).

The following disclosures of financial relationships have been made by the program planners and presenters:

Financial Relationship Key: G-Grant/Research Support C-Consultant/Scientific Advisor S-Speaker’s Bureau E-Employee O-Other N-Nothing to disclose Resolution Key R1-Restricted to Best Available Evidence & ACCME content validation statement R2-Removed/Altered Financial Relationship R3-Altered Control R4-Peer Review with 2nd method of resolution

Last Name First Name Disclosure Resolution Off-Label Use

Perry Allison N N/A N/A

Grubbs Kenneth N N/A N/A

Parker Jay N N/A N/A

Chrobak Bernice N N/A N/A

Graber Mark N N N

Anderson Richard N N/A N

Disclosure

Questions? Contact Us at [email protected] or 617-391-9900

mailto:[email protected]�


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Learning objectives

* Identify diagnostic error as a major element of risk in their practices * Discuss the importance of diagnostic error including the costs and consequences to patients and organizations * Perform a root cause analysis based on the factors known to contribute to diagnostic error * Use tools provided to reduce the risks of diagnostic error in their own practice or organization

Mark L Graber MD FACP Senior Scientist, Patient Safety Portfolio, RTI International Professor Emeritus, Dept of Medicine, SUNY Stony Brook, NY [email protected]

NPSF Professional Learning Series presents:

November 16, 2011

The new kid on the patient safety block: Diagnostic Error in Medicine

Richard E. Anderson, M.D., F.A.C.P Chairman and Chief Executive Officer The Doctors Company


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Diagnostic Errors

Falls

Med Errors Wrong Site

Surgery


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Doctors: I don’t make

mistakes !

Hospitals: Its not OUR

problem !

Diagnostic errors fall in our collective blind spot

Nurses: Its not MY problem !


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DxNos

Tician

MD

Diagnosis: “The most critical of a physician’s skills. It is every doctor’s measure of his abilities; it is the most important ingredient in his professional self image.”

Pat Croskerry - 2008


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Estimates of the Diagnostic Error Rate

Pathology, Radiology

Although higher numbers can be found under artificial conditions, the estimated error rate in the real world is near 2%

Clinical Lab

Varies by test, lab, etc, but overall error rate is < .1%


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Estimates of the Diagnostic Error Rate Patient Surveys

One third of patients relate a Dx error that affected themselves, a family member, or close friend

Second reviews

10-30% of breast cancers are missed on mammography;1-2% of cancers misread on biopsy samples

Standard pts Internists misdiagnosed 13% of patients presenting with common conditions to clinic (COPD, RA, others)

Look backs 30% of subarrachnoid hemorrhage misdiagnosed; 39% of dissecting AAA delayed diagnosis; 25-50% of women with cervical cancer – last PAP abnl on re-read

Autopsies Major unexpected discrepancies that would have changed the management are found in 10-20%

Expert guess Arthur Elstein: 10%


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The death of one man is a tragedy, the death of millions is a statistic.

Joseph Stalin (?)

John Ritter Maurice Gibb


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Where do these errors happen ?

What are the common

conditions ?


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% adverse events related to diagnostic error: Harvard Medical Practice Study: 17% Colorado & Utah: 7% Canadian Adverse Event: 10%

Inpatient Settings


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Diagnostic Error in Ambulatory Settings Systematic Review of 21 publications: Cancer In a series of 56 cases, 8 had serious delays in dx Dementia Every pt in a small town was screened: 9% had dementia but only

4% had been diagnosed Fe-def anemia High incidence of non-investigation & missed cancer, esp females. Asthma Median delay making the Dx: 3 years, 7 visits Tremor Of 402 pts with presumed Parkinsons, dx correct in only half Error-promoting factors: • Atypical & nonspecific presentations • Rare conditions • Comorbid conditions

Kostopoulou, Delaney and Munro. Diagnostic difficulty and error in primary care – A systematic review. Family Practice 400-413, 2008


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Diagnosis

cases % Pulmonary embolism 26 4.5%

Poisoning, ADR, overdose 26 4.5% Lung cancer 23 3.9%

Colorectal cancer 19 3.3% Acute coronary syndrome 18 3.1%

Breast cancer 18 3.1% Stroke 15 2.6%

Congestive heart failure 13 2.2% Fracture 13 2.2% Abscess 11 1.9%

Pneumonia 10 1.7%

Aortic aneurysm/dissection 9 1.5%

Schiff, G. D., O. Hasan, et al. (2009). Diagnostic Error in Medicine - Analysis of 583 Physician-Reported Errors. Arch Int Med 169(20): 1881-1887.


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What is the cost of diagnostic error ?


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Claims Data: High-severity Cases Top allegation category: Diagnosis Error


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The rising cost of diagnosis

Igelhart NEJM 2009. Vol 360 p1030


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Costs and consequences of Dx Error

• Inappropriate testing (Defensive medicine) • Preventable re-admissions; Preventable

return visits to the ER; Preventable rescue events.

• Physical and psychological harm ▫ False positives: Your mammogram shows a

nodule – I think you have cancer ▫ False negatives: Your chest pain sounds

musculoskeletal (or is it a heart attack ?)


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How can we analyze and understand

diagnostic error ?


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Diagnosis

History Exam

Tests


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Present; F/up1%

History 10%

Exam10%

Lab & Radiol Testing

46%

Assessment33%

N= 583 Cases

Where & When in Dx Process are Errors Occurring?

Schiff, G. D., O. Hasan, et al. (2009). "Diagnostic Error in Medicine - Analysis of 583 Physician-Reported Errors." Arch Int Med 169(20): 1881-1887.


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What went wrong ?


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Missed and Delayed Diagnoses in the Ambulatory Setting Gandhi et al. Ann Int Med 2006. 145:488-496

Analyzed 307 closed malpractice claims involving an outpatient diagnostic error from 4 carriers

• Of the 307 cases: ▫ 55% failure to obtain an appropriate test ▫ 45% failure to create an appropriate plan for

follow-up ▫ 42% failure to obtain the appropriate history or

physical exam ▫ 37% incorrect interpretation of diagnostic tests


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The Patient

The Healthcare

System

The Clinician

HARM


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Etiology of Diagnostic Error

Both System and Cognitive Errors

46%

Cognitive Error Only28%

System Error Only19%

No Fault Error Only7%

Average: 6 distinguishable errors/case


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DOMAIN EXAMPLE Communication Critical information not passed to the

next provider Coordination of Care Medical records not available Access to Experts No Radiologist on nights Safety Culture Same errors keep happening Supervising Trainees Trainee misdiagnosis at night Work Pressure Rushed history – missed key piece of

data Distractions, etc Fatigue, interruptions causing slips Diagnostic Testing Pre- and Post-analytical errors

System-Related Diagnostic Error


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DOMAIN EXAMPLE Inadequate knowledge Doctor didn’t know the disease could

present this way Faulty data collection Sloppy physical exam; failing to

review the existing medical records Faulty synthesis Faulty context and anchoring errors;

Premature closure (failing to consider other possibilities)

Cognitive-Based Diagnostic Error


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“ Say … What’s a mountain goat doing

way up here in a cloud bank ?”


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Premature closure = Satisficing

= Falling in love with the first puppy …

(Herbert Simon)


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So where are we ?


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Diagnostic Errors

• Are more common than they should be. They cause enormous harm and lost costs.

• Typically involve multiple breakdowns in our safety systems, and involve both cognitive and system-related issues. They can be analyzed using RCA approaches like any other medical error


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What can we do to reduce the

likelihood of diagnostic error ?


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AHRQ: Literature Review to Identify Interventions to Reduce Dx Error

Mark Graber, Hardeep Singh

RTI International

Systems: 43 articles: 6 trials Cognitive: 157 articles: 37 trials


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Strategies to Reduce Dx Error

Promote a culture of safety

Address the common system flaws to contribute to diagnostic error

Provide decision support resources

Encourage second opinions

Develop pathways for feedback

HEALTHCARE SYSTEMS


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HEALTHCARE SYSTEMS

•IMPROVE COMMUNICATION

•Take advantage of the EMR

• Better alerts for critical test results; Better data displays

• Make sure expertise is available when needed

• Coordinate care across different providers, sites, systems

• Making sure prior medical data is available for review

• Empowering patients; Encourage feedback

• Ensure screening tests are done


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Help minimize system flaws: Ensure good communication Help ensure test results are acted upon

Help the patient communicate

Be the watchdog for deterioration

NURSES – Our Safety Net


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Be a good historian

Keep accurate records of your tests

SPEAK UP ! What else could this be ?

Get real: Diagnosis is just playing the odds

Ask what to expect & what the plan is for follow-up

PATIENTS


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System errors: Bring them to attention and make sure they get fixed.

Cognitive errors:

•Improve your knowledge base

•Improve your clinical reasoning & use EBM

•Take advantage of decision support resources and get help when needed

PHYSICIANS


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Cost

Time

Effort

less more

more

Accuracy, Reliability

Inductive Reasoning

Expert Thinking

Heuristics, Automatic

EXPERT

NOVICE

ME

GET HELP

REFLECTIVE PRACTICE

Monitoring, antidotes


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Problems Solutions

• Faulty context • Premature closure • Failed intuition

• Reflection – What else could this be ?

• Be comprehensive


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How to be Comprehensive

Use mnemonics and tricks: ROWCS VITAMIN C C & D Electronic decision support

(Isabel, DxPlain)


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VITAMIN C C & D 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


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DXplain •Chest tightness •Troponin elevation •Hypoxemia


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A Checklist for Diagnosis

Obtain YOUR OWN, COMPLETE medical history, & a FOCUSED and PURPOSEFUL physical examination Generate some initial hypotheses; Use EBM; Pause to reflect – Take a diagnostic “time out”:

•Was I comprehensive ? •Did I consider the inherent flaws of heuristic thinking ? •Was my judgment affected by any other bias ? •Do I need to make the diagnosis NOW, or can I wait ? •What’s the worst case scenario ? What are the ‘don’t miss’ entities ?

Embark on a plan, but acknowledge uncertainty and ENSURE A PATHWAY FOR FOLLOW-UP Make the PATIENT your PARTNER


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NPSF Education Module: Reducing Diagnostic Error

•Lectures from Gordy Schiff, Geetha Singhal, Mark Graber

•Workshop on diagnostic error

•Patient and Family Tools and Resources

•Pocket Guide – How Doctors Think

•Ask Me 3

1. Have I told you enough so you can understand my problem?

2. What could be causing my problem?

3. When will I get my test results, and will my other doctors get the results too?


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In Summary …

• Diagnostic error is a common and serious problem, causing enormous harm

• These errors reflect latent system flaws and shortcomings in cognition

• The problem is largely ignored by all concerned

• ITS TIME TO DO SOMETHING …..

And THERE’S A JOB FOR EVERYONE

Documents

Npsf slides graber