Case Closed: Wendy L. Longmire, JD Diagnostic Error Ortale, Kelley, Herbert & Crawford
Agenda What we will cover Diagnostic Error Data • • Cognitive Factors Systems Issues • • Lessons Learned from Case Studies Appropriate • Supervision Improvement • Strategies
Why a course on Diagnostic Error? Diagnostic error is the patient’s • #1 concern when surveyed • 40,000 – 80,000 deaths/year • 1 in 20 primary care patients involved diagnostic error every year • More than half happen in Ambulatory care The toll of Dx Error, Leape et al. JAMA 288:2405, 2002 Singh et al. BMJ Qual Safety 21: 93-100, 2012
National Data (PIAA) Internal Medicine, General and Family Practice • Most prevalent and expensive misadventure: Diagnostic Error • Most expensive condition: Chest pain Most prevalent misdiagnosed condition: • Malignant neoplasms of the bronchus and lung Physician Insurers Association of America-PIAA
Top Misdiagnosed Conditions Cancer • • Infections • Pulmonary embolism Acute coronary syndrome • • Fractures Cerebrovascular disease • • Appendicitis Pennsylvania Patient Safety Authority 2010
Common Failures in Diagnosis • Inadequate H & P Failure to follow a • cancer screening protocol • Failure to include cancer in differential dx • Failure to order appropriate tests or referral Incorrect interpretation of tests • • Failure to track tests and notify patients • Inadequate discharge planning or follow-up
Challenges to Reliable Diagnosis • Atypical presentation or unusual course • Cognitive – recognizing acuity/severity • Patient factors • Noncompliant with treatment, failure to follow-up • Poor historians or language barriers • Systems issues • Access to testing • Delays or misinterpretations • Fragmented care
Heuristics: A Double-Edged Sword • Mental shortcuts commonly used in decision-making and frequently correct. But, can lead to faulty reasoning. • “Familiarity breeds conclusions” • Occam’s razor is an example of a medical heuristic; it dictates that the simplest explanation for all presenting symptoms should be sought • Common things are common • If you hear hoofbeats, think of horses instead of zebras Elstein AS, Schwartz A. Clinical problem solving and diagnostic decision making: selective review of the cognitive literature. BMJ 2002; 324:729–732.
Cognitive Bias • Anchoring – tendency to stay with an original diagnosis or make a “snap judgment” • Availability - immediately comes to mind • Premature closure - failure to consider possibilities once initial diagnosis is reached • Confirmation bias - assigning preference to findings that confirm diagnosis or strategy • Context errors - clinician biased by patient history, previous diagnosis, etc. leading to the wrong context for diagnosis
“How Doctors Think” Dr. Groupman focuses on how the doctor-patient interaction influences diagnosis and espouses: • Practice conscious, reflective review • Patients should actively participate in care • Shore up knowledge gaps Suggested asking two questions before diagnosing: 1. “What else might this be?” 2. “Could there be two things going on here?” How Doctors Think, Jerome Groupman, MD
What Happened Here? • Heuristics/Cognitive issues • Adequate H & P? • Differential diagnosis? • Communication/Systems failures • Hand off failure • Problems with documentation • Subjective, derogatory comments
Complex Care Is a Team Effort Strive for: • Effective Communication • Consistent Office Processes and Systems • Good Medical Record Documentation
Poor Communications = Errors 70% of sentinel events reported to Joint Commission caused by poor communication • 44% breakdown in communication with patients or among colleagues (handoffs) • 21% misinformation in the medical record • 18% mishandling of patient requests or messages • 12% inaccessibility of medical records • 5% inadequacy of reminder systems Source: Woolf SH, Kuzel AJ, Dovey SM, et al. A string of mistakes: the importance of cascade analysis in describing, counting, and preventing medical errors. Ann Fam Med 2004 Jul-Aug;2(4):317-26.
Continuity of Care • You don’t need to find and fix everything • Average patient has 3.6 providers • Refer to specialists and communicate the relationship to patients • ER doctor: “It’s important you see Dr. Reed for this belly pain.” • Ask patient to update you on other care providers and treatment plans • “What did the ER doctor tell you this could be?”
Handling Telephone Calls • Do you have written policies ? • Do you carefully prioritize phone calls for the physician to ensure urgent ones are addressed immediately? • Do you track 2 nd or 3 rd call for same problem? • Do you document after-hours calls?
Documenting After-Hours Calls At a minimum, document: • Calls about positive test results reported to patients • What was action taken/patient advised? • Medical advice given or history obtained • To consultants about a specific patient • Medication prescribed or changed SVMIC offers free after-hours message pads
What Happened Here? • Faulty Systems • Differing Expectations • Radiologist would call in report • Communication Breakdowns • No news is good news
Tracking • Diagnostic tests • Patient referrals • Patients requiring follow-up • “No-shows” or cancelled appointments
The Patient as a Safety Net • Set expectations up front (Patient agenda) • Disclose the diagnosis to the patient and what to expect • Give the patient an approximate date to be notified • Tell the patient to call back if s/he doesn’t hear back within timeframe • “No news” IS NOT “Good news”! • “We will call you with your results. If you don’t hear from me or my office staff within 10 days, please call the office.”
Tracking Documentation • Keep a paper log (example in book) • EHR can track and send an alert/reminder • Diagnostic tests or consultations • Date the report is anticipated • Date report received • Patient notified and action taken • Not filed until: provider review, action taken, pt. notified • Missed/cancelled appointments: • Contact patient - # of attempts commensurate with situation • Contact referring physician (form in book)
EHR “The Sword” • Copy/paste and cloned notes perpetuate inaccurate or contradictory records • Templates can lead to an inaccurate diagnosis • Position your EHR so it isn’t a barrier between you and the patient • Data display issues such as hidden fields, multiple windows and need to scroll down or view a second page
EHR “The Shield” • Decision support tools may help with diagnosis • Decrease errors in calculation, faulty memory • Update problem lists, medications and allergies • Legibility of notes • Alerts (when not disregarded) • Tracking, recalls and reminders • Document patient education • Create after-visit summary
Carryover Example Two entries repeated at EACH VISIT for a 3 year period for cancer patient: History: Medications: “patient was diagnosed with “no new medicines renal cancer 1 month ago” prescribed”
Supervising Relationships Supervising Relationships • Midlevel practitioners • Office Staff
Foster Collaborative Relationships • Maximize staff to their highest credentials • Teach and appropriately delegate to staff who then take ownership and initiative • Staff huddles • Encourage broader situational awareness “Doctor, didn’t you want to repeat the CBC this visit?”
Team Participation • Ensure important information gets relayed to the next level of care • “Front desk notifies nurse/MA that patient arrived short of breath and mentioned he had some chest pain.” • Be part of the safety net: Does what you see fit with the medical diagnosis? If not, speak up. • After-visit summary and follow-up plans • Use “teach-back” to ensure patient understanding • Provide take home educational materials • Call backs for follow-up
Midlevel Practitioner Supervision • Physician or substitute physician must be available for consultation at all times • Must have experience and/or expertise in the same area of medicine as the MLP • Must authorize drugs on the formulary • Jointly developed protocols
Midlevel Practitioner Supervision All supervising physicians must: • Review a minimum of 20% of records • 100% review of records if controlled substance prescription given • Review within 10 days and certify by signature within 30 days • Visit remote sites every 30 days
Diagnostic Tools • Evidence-based medicine (guidelines, clinical protocols – document deviations) • Today, there is at least one published protocol for virtually every diagnostic category • Recommendations from specialty societies • Agency for Healthcare Research and Quality: www.guidelines.gov • Error checklists
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