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
Human Error Skill Based – error rate 1:1000 Rule Based – error rate 1:100 Knowledge Based – error rate 1:2
ExpertA. Elstein: 10-15% Patient Survey One third relate a Dx error affected themselves, family Second Reviews Radiology and Pathology: 2-5% cancers missed Look backs30% of subarachnoid hemorrhage misdiagnosed; 39% of dissecting AAA delayed diagnosis; A third of neurological diagnoses wrong or likely wrong AutopsyMajor unexpected discrepancies that would have changed the management are found in 10-20% Estimates of Dx Error Rate
Estimates Diagnostic Error Rate Trauma8% of pts have missed injuries General ER.6% of 5000 admitted pts at Wayne State MI2-3% of pts sent home have an MI; 90% of pts admitted don’t have an MI or ACS Liability47% claims high severity cases alleged Dx related Outpatient Clinic 1:20 patients experience dx error each year
Diagnostic Errors Are common and cause enormous harm Estimates 40,000-80,000 annual deaths Overlooked with emphasis on system improvement Measurement tools lacking
Problems Solutions Faulty context Premature closure Failed heuristic Framing errors Consider the opposite Crystal ball experience Reflection Be comprehensive Learn the antidotes How can we make diagnosis more reliable ?
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.
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 Complexity in Medicine
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
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
Structured Reflection Vascular Infections & intoxications Trauma & toxins A uto-immune M etabolic Idiopathic & iatrogenic N eoplastic C ongenital C onversion (psychiatric) D egenerative E ndocrine
Possible Solutions National Agenda Research Health IT Clinical Reasoning Education
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
Case Studies Maine Medical Center –Physician Reporting SoCal Kaiser Permanente –Electronic Records to Trace Diagnostic Error