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This document announces a continuing medical education event presented by the National Patient Safety Foundation on November 16, 2011 about diagnostic errors in medicine. The event features two speakers: Richard Anderson, MD, who will discuss the importance of diagnostic errors, their costs and consequences; and Mark Graber, MD, who will perform a root cause analysis of factors known to contribute to diagnostic errors. The learning objectives are to help attendees identify diagnostic error as a risk, discuss its importance, analyze root causes, and learn tools to reduce diagnostic errors. The document provides background information on estimates of diagnostic error rates from different studies and settings.
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- 1. NPSF Professional Learning Series presents: The new kid on the patient safety block: Diagnostic Error in Medicine November 16, 2011 Richard E. Anderson, M.D., F.A.C.P Mark L Graber MD FACP Chairman and Chief Executive Officer Senior Scientist, Patient Safety Portfolio, RTI International The Doctors Company Professor Emeritus, Dept of Medicine, SUNY Stony Brook, NY mgraber@rti.org
- 2. 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) 2 NPSF Professional Learning Series November 16, 2011
- 3. Disclosure 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: 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 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 Questions? Contact Us at info@npsf.org or 617-391-9900 3 NPSF Professional Learning Series November 16, 2011
- 4. 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 4 NPSF Professional Learning Series November 16, 2011
- 5. NPSF Professional Learning Series presents: The new kid on the patient safety block: Diagnostic Error in Medicine November 16, 2011 Richard E. Anderson, M.D., F.A.C.P Mark L Graber MD FACP Chairman and Chief Executive Officer Senior Scientist, Patient Safety Portfolio, RTI International The Doctors Company Professor Emeritus, Dept of Medicine, SUNY Stony Brook, NY mgraber@rti.org
- 6. Diagnostic Errors Falls Wrong Site Med Errors Surgery 6 NPSF Professional Learning Series November 16, 2011
- 7. Nurses: Its not MY problem ! Hospitals: Its not OUR problem ! Doctors: I don’t make mistakes ! Diagnostic errors fall in our collective blind spot 7 NPSF Professional Learning Series November 16, 2011
- 8. 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 8 NPSF Professional Learning Series November 16, 2011
- 9. Estimates of the Diagnostic Error Rate Pathology, Although higher numbers can be found under artificial Radiology 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% 9 NPSF Professional Learning Series November 16, 2011
- 10. Estimates of the Diagnostic Error Rate Patient One third of patients relate a Dx error that affected Surveys themselves, a family member, or close friend Second 10-30% of breast cancers are missed on reviews 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% 10 NPSF Professional Learning Series November 16, 2011
- 11. The death of one man is a tragedy, the death of millions is a statistic. Joseph Stalin (?) Maurice Gibb John Ritter 11 NPSF Professional Learning Series November 16, 2011
- 12. Where do these errors happen ? What are the common conditions ? 12 NPSF Professional Learning Series November 16, 2011
- 13. Inpatient Settings % adverse events related to diagnostic error: Harvard Medical Practice Study: 17% Colorado & Utah: 7% Canadian Adverse Event: 10% 13 NPSF Professional Learning Series November 16, 2011
- 14. Diagnostic Error in Ambulatory Settings Systematic Review of 21 publications: Cancer In a series of 56 cases, 8 had serious delays in dx DementiaEvery 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 14 NPSF Professional Learning Series November 16, 2011
- 15. Diagnosis cases % Pulmonary embolism 26 4.5% Poisoning, ADR, overdose 26 4.5% Lung cancer 23 3.9% Schiff, G. D., O. Hasan, et al. (2009). Colorectal cancer 19 3.3% Diagnostic Error in Acute coronary syndrome 18 3.1% Medicine - Analysis of 583 Breast cancer 18 3.1% Physician-Reported Errors. Arch Int Med 169(20): Stroke 15 2.6% 1881-1887. Congestive heart failure 13 2.2% Fracture 13 2.2% Abscess 11 1.9% Pneumonia 10 1.7% Aortic aneurysm/dissection 9 1.5% 15 NPSF Professional Learning Series November 16, 2011
- 16. What is the cost of diagnostic error ? 16 NPSF Professional Learning Series November 16, 2011
- 17. Claims Data: High-severity Cases Top allegation category: Diagnosis Error 17 NPSF Professional Learning Series November 16, 2011
- 18. The rising cost of diagnosis Igelhart NEJM 2009. Vol 360 p1030 18 NPSF Professional Learning Series November 16, 2011
- 19. 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 ?) 19 NPSF Professional Learning Series November 16, 2011
- 20. How can we analyze and understand diagnostic error ? 20 NPSF Professional Learning Series November 16, 2011
- 21. History Exam Diagnosis Tests 21 NPSF Professional Learning Series November 16, 2011
- 22. Where & When in Dx Process are Errors Occurring? Present; F/up 1% Assessment 33% History 10% Exam 10% Lab & Radiol Testing 46% N= 583 Cases 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. 22 NPSF Professional Learning Series November 16, 2011
- 23. What went wrong ? 23 NPSF Professional Learning Series November 16, 2011
- 24. 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 24 NPSF Professional Learning Series November 16, 2011
- 25. The Healthcare System The Clinician The Patient HARM 25 NPSF Professional Learning Series November 16, 2011
- 26. Average: 6 distinguishable errors/case Etiology of Diagnostic Error No Fault Error Only 7% Both System and System Error Only Cognitive Errors 19% 46% Cognitive Error Only 28% 26 NPSF Professional Learning Series November 16, 2011
- 27. System-Related Diagnostic Error 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 27 NPSF Professional Learning Series November 16, 2011
- 28. Cognitive-Based Diagnostic Error 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) 28 NPSF Professional Learning Series November 16, 2011
- 29. “ Say … What’s a mountain goat doing way up here in a cloud bank ?” 29 NPSF Professional Learning Series November 16, 2011
- 30. Premature closure = Satisficing = Falling in love with the first puppy … (Herbert Simon) 30 NPSF Professional Learning Series November 16, 2011
- 31. So where are we ? 31 NPSF Professional Learning Series November 16, 2011
- 32. 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 32 NPSF Professional Learning Series November 16, 2011
- 33. What can we do to reduce the likelihood of diagnostic error ? 33 NPSF Professional Learning Series November 16, 2011
- 34. 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 34 NPSF Professional Learning Series November 16, 2011
- 35. Strategies to Reduce Dx Error HEALTHCARE SYSTEMS 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 35 NPSF Professional Learning Series November 16, 2011
- 36. Strategies to Reduce Dx Error 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 36 NPSF Professional Learning Series November 16, 2011
- 37. Strategies to Reduce Dx Error NURSES – Our Safety Net Help minimize system flaws: Ensure good communication Help ensure test results are acted upon Help the patient communicate Be the watchdog for deterioration 37 NPSF Professional Learning Series November 16, 2011
- 38. Strategies to Reduce Dx Error PATIENTS 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 38 NPSF Professional Learning Series November 16, 2011
- 39. Strategies to Reduce Dx Error PHYSICIANS 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 39 NPSF Professional Learning Series November 16, 2011
- 40. NOVICE more Monitoring, Inductive antidotes Reasoning GET HELP REFLECTIVE PRACTICE Cost Heuristics, Automatic Time ME EXPERT Effort Expert Thinking less more Accuracy, Reliability 40 NPSF Professional Learning Series November 16, 2011
- 41. Problems Solutions • Faulty context • Reflection – What else • Premature closure could this be ? • Failed intuition • Be comprehensive 41 NPSF Professional Learning Series November 16, 2011
- 42. How to be Comprehensive Use mnemonics and tricks: ROWCS VITAMIN C C & D Electronic decision support (Isabel, DxPlain) 42 NPSF Professional Learning Series November 16, 2011
- 43. 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 43 NPSF Professional Learning Series November 16, 2011
- 44. DXplain •Chest tightness •Troponin elevation •Hypoxemia 44 NPSF Professional Learning Series November 16, 2011
- 45. 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 45 NPSF Professional Learning Series November 16, 2011
- 46. 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? 46 NPSF Professional Learning Series November 16, 2011
- 47. 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 47 NPSF Professional Learning Series November 16, 2011