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Robin Warshafsky Deputy Medical Director, IC24

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1 Robin Warshafsky Deputy Medical Director, IC24
Lessons from serious incident reviews Robin Warshafsky Deputy Medical Director, IC24

2 SEPSIS IN OUT OF HOURS Gatwick 24.02.16

3 Sepsis- A Patient Story
Quality and Patient Safety Conference 24th November 2015 AMEX Brighton L’s story presented by Jo Habben and Dr Robin Warshafsky

4 ‘Patients who are obviously critically ill are likely to be identified without the need for new efforts. However, there are some patients with severe sepsis with less immediately obvious signs of critical illness. Some of this group might be identified earlier with greater awareness and targeted clinical assessment.’ Thankyou to L’s family who have agreed for her story and the lessons learned to be shared.

5 Swiss Cheese Model James Reason

6 Raised via NHSE complaints process
Timeline 2nd June- 18th July 2014 02/06- GP- Productive Cough (2.5 weeks OTC)- Antibiotics/PPI for reflux 10/06 GP- Raised temp/rash- Antihistamine/Emollient 29/06 A&E – Fall fractured wrist- Ortho (Regional block)- IV Antibiotic cover (anaesthetist noted productive cough) 08/07 GP Malaise/unwell/abdo pain/temp telephone advice- Paracetamol 11/07 GP- Friday- Unwell high temp, ‘squiffy’ breathless, vomiting, abdo pain- diagnosed - Gastroenteritis 12/07 Sat- 111 developed diarrhoea- Gastroenteritis (NHS Pathways D&V) Sat OOH- Receptionist cancels booked appointment informs GP of D&V GP telephone advice- High temp/abdominal pain/coughing- diagnosis- Gastroenteritis 14/07 Family contact GP- Monday am- Collapse – Paramedic Practitioner called ‘Sepsis’- wrong address/delay 18/07 Thursday -RIP Multi Organ Failure (cause unknown)- implication for family

7 Care and service delivery problems
Primary Care Failure to recognise that Patient L presented with Systemic Inflammatory Response Syndrome (SIRS) and sepsis. Failure to complete a full set of clinical observations when Patient L presented with signs of infection-Temperature/Pulse/Blood Pressure/Respiratory Rate/Oxygen Saturation/Blood Glucose. Failure to provide ‘safety netting’ advice to both Patient L and Patient L’s family Failure to instigate an immediate 999 response when Patient L presented in septic shock. NHS 111 and GP OOH Failure to speak to Patient L directly during telephone triage/consultation. Failure to recognise the severity of Patient L’s condition and treat accordingly. Failure to offer face to face clinical consultation.

8 Consider: Pressure not to over prescribe antibiotic therapy in Primary Care. On discussion, GP’s report time constraints in practice, in order to complete a full clinical examination and observations- due to the 10 minute appointment allocation. GP’s also report challenges with referral to secondary care, with the system pressures noted on both ED and medical assessment units. Patients are actively encouraged, due the risk of transferring infection such as Norovirus, not to attend hospital if they have a history of D&V.

9 cause unknown

9% major diagnostic error undetected whilst alive in autopsy studies* 10–15% estimated diagnostic error rate* minority of errors caused by knowledge deficits: 3.4%* diagnostic errors per case** *Berner ES, Graber ML. Overconfidence as a cause of diagnostic error in medicine. Am J Med 2008;121 (Suppl):2–33. **Graber, M et al. Diagnostic error in Internal Medicine Arch Intern Med 2005;165: EPIDEMIOLOGY OF DIAGNOSTIC ERROR Diagnostic error rate Reported rates vary from 10-20%. Of course, we should be talking about preventable diagnostic errors, not ones where it took some time after the initial clinician assessment for the condition to become diagnosable by most clinicians. A 2009 article in the BMJ entitled, Errors in clinical reasoning: causes and remedial strategies noted that almost 50% of adverse events occurring in hospitals involved errors of reasoning or decision quality (failure to elicit, synthesise, decide or act on clinical information). Such reasoning errors led to death or permanent disability in 25% of cases & 75% were deemed highly preventable. 12 DIAGNOSTIC ERROR Knowledge deficits “It is rarely a knowledge deficit that leads to a diagnostic error; more commonly, it is flawed thinking.” Although more knowledge is of course necessary, once painfully acquired, it is not in itself sufficient to help us avoid diagnostic error. It is involved in diagnostic error less than 5% of the time. Again, the cognitive psychologists tell us that the average limits of human working memory is for 7 discrete items. It is thought that there about 13, 000 known conditions. How do you evaluate the other 12, 993 when formulating a ddx? Additionally, there are 4, 000 possible diagnostic tests and 6, 000 medications, treatments and procedures. However, there is a caveat. It is said that you can’t diagnose what you don’t know about.

Evolutionary Psychology Cognitive Modules & Cognitive Dispositions to Respond 30-40 developed in the ‘simple’ environment of the caveman Whilst there are a number of systems errors, stacking neatly with individual errors to align the holes in the Swiss cheese model, I am going to focus on what the individual clinician can ultimately do differently to hopefully avoid this kind of tragedy. Evolutionary Psychology People called evolutionary psychologists reckon that early man evolved through natural selection, decision making pathways hard wired into the brain that allowed for rapid solving of problems. Is that movement of grass in the savannah characteristic of something that might eat you, or something that you might be able to eat? Literally life saving decisions one way or the other had to be made in split seconds through pattern recognition. It is thought that critical changes probably occurred about time of emergence of Cro-Magnon about 30,000 –50,000yr ago and that no major changes have occurred since then. We still use pattern recognition to solve medical diagnostic problems. A large part of the time they do lead to the right diagnosis. Critically however, they can also lead to error. no longer adaptive in the complex environment of modern medicine

12 COMMON HEURISTICS If it looks like a duck, sounds like a duck, and walks like a duck, it is a duck Common conditions occur commonly (including their atypical variants): “If you hear hoof beats, don’t think zebras” Look for a single diagnosis that can explain all the findings (Occam’s razor) The best medicine may be to do nothing—first do no harm Treat the patient, not the numbers Heuristic – from Greek, I discover = rule of thumb, approximate only, fast, intuitive, process one thinking, subject to error

13 30 Cognitive Dispositions to Respond - CDRs
Aggregate Bias Anchoring Ascertainment Bias Availability Bias Base rate Neglect Commission Bias Confirmation Bias Diagnostic Momentum Attribution Error Gambler’s Fallacy Gender Bias Hindsight Bias Multiple Alternatives Omission Bias Order effects Outcome Bias Overconfidence Playing the Odds Posterior Probability Premature Closure Psych-Out Errors Representativeness Search Satisficing Sutton’s Slip Triage-Cueing Unpacking Principle Vertical Line Failure Visceral Bias Ying-Yang Out Zebra Retreat 30 CDRs Dr Croskerry and others now call these hard wired pathways, or heuristics, cognitive dispositions to respond. There are about 40 of them. Some with exotic names.

Look at this case from the point of view of how we as clinicians can fall into cognitive traps, and some of the remedies that have been suggested COGNITIVE AUTOPSY

15 SEPSIS RISK IN OOH Risk Factor OOH Period
Extremes of age: <6mos 65yrs ~30% of OOH patients  65 Chronic illness Multiple co-morbidities Recent surgery/hospitalisation Very common Indwelling cath/other devices (recent) Trauma & Burns Common OOH may be a poorly recognised risk area for sepsis presentations due to population that presents

16 THIRD PARTY INERTIA Shivering, fever, or very cold
Extreme pain or general discomfort (“worst ever”) Pale or discoloured skin Sleepy, difficult to arouse, confused I feel like I might die Short of breath Not of course unique to IC24, or OOH. Seen as priority learning item on CQC inspection to OOH provider elsewhere in country recently

17 DIAGNOSTIC MOMENTUM once diagnostic labels are attached to patients, they become stickier and stickier DIAGNOSTIC MOMENTUM The diagnosis of gastroenteritis was voiced or implied by several parties prior to the index telephone consultation: GP at the surgery the day before, the receptionist who assumed this was viral D&V and changed the base to advice Also known as “chart-lore”

18 IN THE CONSULTATION Vomiting x 3 days; V > D ? ≠ VGE
Feverish? Very hot, face looks hot, really hot, very red face 3. Dizzy when gets out of bed (?orthostatic hypotension) 4. “Ate at a pub a few days before symptoms” 5. Partner’s main worries: temperature non-productive frequent/deep cough

19 ANCHORING Fixing on a particular piece of information and then thinking in a constrained, linear way and proceed down only one path

20 CONFIRMATION BIAS Tendency to look for confirming evidence to support a diagnosis rather than look for discomfirming evidence to refute it (despite the latter often being more persuasive and definitive) CONFIRMATION BIAS  Selective seeking out or filtering of information that seems to confirm favoured dx (but in fact may be redundant) & ignoring data that are inconsistent w dx & suggestive of other dx’s Be familiar w & look for, highly sensitive features of favoured dx that should be present & take note of findings that are highly specific for alternative dx’s Cherry picking the evidence to support the premature conclusion

Timeline before death: 7 wk: saw GP with “bad, hacking cough coming from deep within body” Cough continued after course of abx ~6wk: developed rash on legs 5wk: GP >> antihistamine/cream for rash Rash resolved, cough never resolved 3wk: wrist fracture roller blading >> ORIF

22 UNPACKING PRINCIPLE The failure to elicit all relevant information in establishing a differential diagnosis that may result in significant possibilities being missed “Clinicians tended to wrap up when they had gathered only about 60–70% of available critical data” Barrows et al. 1982 UNPACKING PRINCIPLE Includes not doing a full examination including a full set of obs as a default setting for all presentations

23 SUTTON’S SLIP The diagnostic strategy of going for the obvious is referred to as Sutton’s law. The slip occurs when possibilities other than the obvious are not given sufficient consideration. SUTTON’S SLIP takes its name from the apocryphal story of the Brooklyn bank-robber Willie Sutton who, when asked by the Judge why he robbed banks, is alleged to have replied: ‘‘Because that’s where the money is!’’ The diagnostic strategy of going for the obvious is referred to as Sutton’s law. The slip occurs when possibilities other than the obvious are not given sufficient consideration.

24 WELLNESS BIAS (?111) operating in a context with a low prevalence of serious disease Dx07 To contact a Primary Care Service within 12 hours The routine dispositions from 111 create a sector of the workload with a low, but not zero, prevalence of serious disease.

25 PREMATURE CLOSURE the failure to continue considering reasonable
alternatives after a primary diagnosis is reached, is the most common diagnostic error “When the diagnosis is made, the thinking stops” Croskerry, P. Acad Med 2003; 78:775-80 PREMATURE CLOSURE Although I cannot give exact numbers, this is reckoned to be the most common CDR. Acceptance of a dx before it has been fully verified by considering alternative dx’s & searching for data that challenge provisional dx

Develop insight/awareness of biases/CDRs Reduce reliance on memory Specific training Simulation Collegiate ethos of seeking advice without fear of ridicule Make task easier – templates Minimise time pressures Accountability Feedback Awareness of specific clinical scenarios in which classic errors more predictable Checklists 46 COGNITIVE DE-BIASING STRATEGIES Debiasing Strategies Simulation: Videotaping realistic scenarios w ED team allows for review & analysis in a safe setting. Feedback: Practicing medicine without feedback is probably somewhat like sailing a boat without a compass or GPS. But I think that feedback on the scale and of the kind, that we will need requires a systems change. It is tedious for individuals to obtain this on their own. robust morbidity & mortality program that does not "lay blame" Weather forecasters are less biased in their predictions than other types of experts because the system is engineered to provide rapid feedback on accuracy. Ericsson (2007) correctly observes that expert performance is acquired by practice & feedback. Medical students & residents get lots of supervised practice. But how good is the feedback once in clinical practice? How do we learn from errors if we don’t know that an error has occurred? Or if we are not sure if a bad outcome is dt error or just bad luck? Just compare the feedback available to health professionals w that provided continually to concert musicians & professional baseball players, 2 domains where immediate feedback is regularly provided & where mistakes are carefully reviewed. Improving feedback to clinical practitioners may be the most effective debiasing procedure available. Indeed, improving how feedback is provided & used in the clinical setting has been identified as a priority task for g dx’ic errors (Schiff et al. 2005). Common clinical scenarios ass’d w  risk of dx’ic error include back pain in presence of known malignancy, wherein anchoring may cause OA & other common causes of mechanical back pain to be considered over metastatic spinal disease; & patients with dyspnoea,  JVP & hypotension for whom systolic HF is prematurely accepted as dx when PE & cardiac tamponade can present w similar features Temporal arteritis in patients w atypical h/a’s—Anchoring bias & premature closure may cause muscle contraction or tension h/a’s to be dx’d when more sinister diseases such as temporal arteritis need to be considered

27 METACOGNITION High Risk Situations for Diagnostic Error
A “Yes” response to any of these questions puts you at high risk for error Are there “must-not-miss” diagnoses that need consideration? 2.Did I just accept the first diagnosis that came to mind? 3.Are there any pieces that don’t fit? 4.Was this patient handed off to me from a previous shift? 5. Is there data about this patient I haven’t obtained and reviewed? 6.Was this patient seen in A&E or by GP recently for the same problem? the process of conscious attention to our own decision-making METACOGNITION Knowing all this stuff happens is the first step - how dx’s emerge from subconscious processing & inherent biases that can lead to errors Ask yourself what CDRs might be operating here. Are they working for or against, a reasonable diagnosis. If the latter, adjust your thinking. Go through a check list of the most common ones: premature closure, have you closed your mind off to other possibilities Anchoring: have you fastened onto one bit of information at the expense of others Wellness bias: are you subconsciously looking for a benign diagnosis to avoid something, extra work, upsetting the patient Confirmation bias: are you cherry picking the signs/symptoms to fit a prematurely arrived at diagnosis Sutton’s Slip: have you considered some of the rarer, but more serious possibilities Diagnostic momentum: was this diagnosis suggested to you by the patient, a colleague, the medical record  Use both processes: explicitly use both cognitive process strategies can lead to consistent reduction in error rates. Use one to cross check the other. Ie how does it feel, versus how does it look, under careful rational scrutiny. Once you've come up w a working hypothesis, examine it carefully & consciously Consider the opposite, rethink your key assumptions & think about dx’s that you can't afford to miss., Is this a risky scenario by virtue of: Presentation: chest pain/abdominal pain/dyspnoea The provisional diagnosis being one subject to error, ie gastroenteritis, headache reflective practice We do reflective practice occasionally on occasional cases. The next time you consult, try this: Deliberately observe your thinking. Consider the moment when a diagnosis first comes to consciousness as you take that patient’s history. Ask yourself why this diagnosis. Where did it come from? Was it suggested by the patient? Was it suggested by the NHS 111 Health advisor’s note? Was it suggested by a colleague. Realise that this is diagnostic momentum. Was it suggested because the chief complaint is vomiting and you saw two other patients with D&V earlier that shift/surgery, so you call it gastroenteritis, but there is no diarrhea. This is availability bias. Did you anchor onto the vomiting and stop probing? This is premature closure. And then apply the remedies. 7.Was the diagnosis suggested to me by the patient, nurse or another doctor? 8.Was I interrupted/distracted/cognitively overloaded while evaluating this patient?

Take a diagnostic “time out” List a differential diagnosis Consider the opposite Ask “What can’t I explain?” MD 305 rule: Minimum of 3 diagnoses, 2 organ systems COGNITIVE FORCING STRATEGIES Decrease reliance on memory: clinical decision rules, decision-support tools & posters w algorithms & drug doses frees up thinking to focus on dx’ic process.   What is the evidence is that I have ruled out immediate life threatening conditions?

29 What is the worst thing this could be?!!
UNIVERSAL ANTIDOTE What is the worst thing this could be?!! UNIVERSAL ANTIDOTE

30 IC 24 RESPONSES 1. Guidance on Sepsis recognition – “Easily Missed” “cognitive autopsy” in all Easily Missed case reviews 2. Updated IC24 telephone guidance – 3rd party histories 3. IC24 sponsored Webinar on Understanding & Reducing Diagnostic Error ( ) Guidance on Reducing Diagnostic Error - TBA 4. S.M.A.R.T Working in OOH in IC24 Guidance 5. System forcing strategy –”THINK SEPSIS” alert in CLEO

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