1. The Canadian Medical Protective Association © CMPA
10/31/2017
Common Diagnostic Errors
- Decreasing risk in your practice
Shirley Lee MD, MHSc(Ed), FCFP (EM)
Physician Advisor-Practice Improvement, CMPA
McGill Family Medicine Refresher Course 2017
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Faculty / Presenter Disclosure
Faculty: Dr Shirley Lee
Employee of: CMPA
Relationships with commercial interests:
Grants / Research Support:
Speakers Bureau / Honoraria:
Consulting Fees:
Other:
Conflict of Interest - I have no financial or professional affiliation with any organization that can be perceived as a conflict of interest in the context of this presentation.
Copyright - Not to be distributed without written permission of CMPA. No audio recording, video recording, or photography is allowed without CMPA's permission.
Information is for general educational purposes only and is not intended to provide specific professional medical or legal advice or constitute a “standard of care”.
Media Asset Copyright - All non-CMPA audiovisual files are used with permission and for educational purposes only. All rights belong to the original owner as per license agreements – Thinkstock, YouTube and others as required.
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2. Disclaimer Objectives Describe medical-legal risks associated
10/31/2017
Disclaimer
Cases in this presentation are used for educational
purposes only and are based on actual events.
They have been de-identified and/or anonymized to protect privacy.
Please do not photograph or disseminate this information.
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Objectives
Describe medical-legal risks associated
with diagnostic errors
Name 3 common issues seen in CMPA cases involving diagnostic issues
Identify 3 strategies for reducing your medical-legal risk with cases involving a challenging diagnosis
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3. 10/31/2017
Clinical issue + costs
10,209 Legal actions closed
Diagnostic issues account for highest proportion of costs
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25-year US malpractice claims analysis Diagnostic errors most frequent type (28.9%) Highest proportion of total payments (35.2%)
[BMJ Qual Saf 2015;22:672-80]
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4. Pathology/ Diagnostic Imaging
10/31/2017
Is diagnostic error more often associated with certain specialties?
Frequency of diagnostic issues
CMPA closed cases by specialty
Pathology/ Diagnostic Imaging #1
Medical Specialties/
Pediatrics #1
Emergency Medicine #1
Surgical
Specialties/Ob-Gyn #2
Family Medicine/
Psychiatry #1
Anesthesiology/ PM&R
6-14% of cases
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5. Most diagnostic errors involve common conditions
10/31/2017
Most diagnostic errors involve
common conditions
[Myths and Facts About Diagnostic Errors 2013]
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Family Medicine
Listen to BACH
(Lung, Breast, Appendix, Colon, Heart)
The Canadian Medical Protective Association © CMPA [Fam Pract Manag Jul 2012]

6. 73% 14% 25% Psychiatry Process of care analysis of diagnostic errors
10/31/2017
Psychiatry
Suicidality and deteriorating psychosis
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Process of care analysis of
diagnostic errors
Assessment and Testing, Management investigation processing and and follow-up
interpretation
73% 14% 25%
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7. Common Cognitive Biases
10/31/2017
Not just due to provider issues
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Anchoring
Premature closure
Search satisfaction
Common Cognitive Biases
Zebra retreat
Bandwagon effect
Attribution error
Authority bias
Availability bias
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8. Have I ruled out the most serious diagnosis?
10/31/2017
Addressing cognitive pitfalls
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“What else could this be?”
Cognitive forcing strategies
Have I ruled out the most serious diagnosis?
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Does something not fit?
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Is there a cognitive bias?

9. In high-risk situations…
10/31/2017
In high-risk situations…
Pause to reflect Take a diagnostic ‘time out’
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What else could this be?
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Make sure the patient knows when and how to get back to you if necessary
What would the courts say?
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10. A normal, prudent practitioner of similar training and experience
10/31/2017
Standard of care
A normal, prudent practitioner of similar training and experience
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Courts do not expect perfection
“A doctor is not expected to be infallible, only to exercise reasonable care, skill and judgment in coming to a diagnosis. If this is done, the doctor will not be held liable even if the diagnosis is mistaken.”
(Picard & Robertson)
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11. Hindsight and hindsight bias
10/31/2017
Hindsight and hindsight bias
BEFORE arriving
at a final diagnosis
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The puzzle is solved, the final diagnosis is clear
AFTER determining AFTER a delay in
the final diagnosis making a diagnosis
or a misdiagnosis
CMPA experience
Diagnostic delays/misdiagnosis
Deficient history & general assessment
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12. Vital signs important to review
10/31/2017
Failure to document pertinent history, physical findings, and rationale for DDx
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Vital signs important to review
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13. Repeated presentations for same complaint
10/31/2017
In diagnostic delays with failure to obtain/ interpret vital signs 80% had unfavourable outcomes for the MD
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Repeated presentations for same complaint
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14. Does a clinical algorithm/ guideline suggest testing?
10/31/2017
Failure to perform diagnostic tests or refer to a specialist
Does a clinical algorithm/ guideline suggest testing?
Does something not fit?
Is this a return visit?
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Delay / failure to assess patient

15. Deficient assessments prevalent in CMPA cases
10/31/2017
Diagnosis – the 4 D’s:
Deficient assessments prevalent in CMPA cases
Diligence with vital signs, repeat visits,
concerns from patients/staff
Duty to follow up tests
Document: assessment, discussion, DDx, discharge instructions
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Take home points
Be aware of cognitive biases
When patient does not respond to your
treatment, ask “What else could it be?”
Ensure reliable system to follow up investigations
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16. 10/31/2017
@cmpamembers
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