quick ?

Gerrit Jager gerrit.jager at PLANET.NL
Sat Apr 26 13:10:53 UTC 2014


Indeed, it get complex. The discussion started  about the definition of
diagnostic errors.

I like the word ³error²  (³errare²,  wandering from the truth, even if the
truth may be unknown²)   In our language (Dutch) we use the negative verbs
misses and faults. 

The words of Jerome Kassirer ³Absolute certainty in diagnosis is
unattainable, no matter how much information we gather, how many
observations we make, or how many tests we perform.² (Our Stubborn Quest for
Diagnostic Certainty, N Engl J Med 1989) are still up-to-date.
We are often wrong for the right reason.

If possible, It will be very challeging to define the line between ³no
fault² diagnostic errors and preventable errors.

Gerrit

Gerrit Jager
Radiologists
The Netherlands 
 


Op 25-04-14 22:46, robert bell <rmsbell at ESEDONA.NET> schreef:

> David, Edward,
> 
> Agree, and this also tied to cost effectiveness, which in turn is linked to
> services available - there may not even be a CT scanner available.
> 
> Doesn't it get complex?
> 
> Rob
> 
> 
> On Apr 25, 2014, at 12:34 PM, Hoffer, Edward P.,M.D. <EHOFFER at MGH.HARVARD.EDU>
> wrote:
> 
>> Excellent point, to which I would like to add that Dr. A will find all sorts
>> of "incidentalomas" on the CT scans, which will require FURTHER testing, most
>> of no avail to the patient.
>>  
>> 
>> Ed
>> Edward P Hoffer MD, FACC, FACP
>> 
>> From: David Gordon, M.D. [davidc.gordon at DUKE.EDU]
>> Sent: Friday, April 25, 2014 1:11 PM
>> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
>> Subject: Re: [IMPROVEDX] quick ?
>> 
>> I am SO GLAD to see Eric's and Manoj's comments appear because they highlight
>> a really important piece of the puzzle.
>> 
>> If all we focus on is the miss or delay rate, we will fail to appreciate the
>> harm that can come by over diagnosis and over treatment. Take a theoretical
>> and extreme example for illustrative purposes:
>> --Doctor A obtains a CT scan on every patient with RLQ pain across the board
>> to make sure appendicitis is not missed. Still may miss a case or 2 over the
>> course of several years due to the intrinsic miss rate of CTs
>> --Doctor B does a selective approach. Using his judgment and sometimes guided
>> by labs, he sometimes will do a CT, sometimes will recommend a clinical
>> recheck the next day, or sometimes tells the patient everything looks fine
>> today and come back as needed for worsening.  In doing this, he may miss a
>> few more cases of appendicitis over the years than Doctor A but avoids
>> hundreds of unnecessary CT scans.
>> 
>> So if the only variable studied is how often a diagnosis is missed, Doctor A
>> will always come out on top when in the more complete picture his overtesting
>> and overtreating style can lead to greater public harm not only through
>> greater cost but also through radiation exposure, adverse medication
>> reactions, drug resistance, and so on.
>> 
>> I am sure we are going to see an explosion of studies looking at how often
>> diagnoses are missed or delayed. I gather the majority will be retrospective
>> studies - at least in these early phases. My fear is that retrospective
>> analysis has many limitations and unmeasured variables, yet it is going to be
>> the results rather than the limitations that will receive greater public
>> attention. Ultimately, this evolving science about how to improve diagnostic
>> efficacy is going to have to balance the harm that can come by both under and
>> over diagnosis. I hope the caution expressed by Eric that we are a long way
>> from safely implementing performance metrics and regulations is heard widely
>> and embraced strongly.
>> 
>> Thanks
>> David
>> 
>> 
>> 
>> 
>> David Gordon, MD
>> Associate Professor
>> Undergraduate Education Director
>> Division of Emergency Medicine
>> Duke University
>>  
>> The information in this electronic mail is sensitive, protected information
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>> requested to notify the sender immediately by return electronic mail, and to
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>> forwarded to or shared unless in compliance with Duke Medicine policies on
>> confidentiality and/or with the approval of the sender.
>> 
>> From: Mittal, Manoj K [MITTAL at EMAIL.CHOP.EDU]
>> Sent: Friday, April 25, 2014 10:50 AM
>> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
>> Subject: Re: [IMPROVEDX] quick ?
>> 
>> Thanks, Eric.
>> That is a useful definition.
>> What concerns me a little bit is that we are labeling events as diagnostic
>> errors based on retrospective review of the chart. This may lead to
>> over-diagnosis of diagnostic errors.
>> 
>> It is far easier to see something as a missed opportunity when one knows the
>> future.
>> When you are with a patient in the office or in the emergency department,
>> though, and the case is not straightforward, there may be some pointers to
>> the final diagnosis, but the trick is to find the signal amongst all the
>> noise. 
>> 
>> It will be useful to test the various differential diagnosis list generators,
>> such as Isabel, prospectively, to see how much they help, and at what cost
>> (in terms of increased testing, imaging, increasing LOS, false positive
>> tests, etc.).
>> 
>> Regards,
>> Manoj Mittal, MD
>> 
>> From: Thomas, Eric [Eric.Thomas at UTH.TMC.EDU]
>> Sent: Friday, April 25, 2014 9:51 AM
>> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
>> Subject: Re: [IMPROVEDX] quick ?
>> 
>> Steve and Colleagues,
>>  
>> In some of the research I have done with Hardeep Singh, we have tried to use
>> definitions of diagnostic errors that allow a reliable and valid measurement
>> to occur.  We mostly avoided the issue of diagnoses that evolve over time.
>>  
>> In some of our work we used the following definition, ³An error was judged to
>> have occurred if adequate data to suggest the final, correct diagnosis were
>> already present at the index visit or if the documented abnormal findings at
>> the index visit should have prompted additional evaluation that would have
>> revealed the correct, ultimate diagnosis.  Thus, errors occurred only when
>> missed opportunities to make an earlier diagnosis occurred based on
>> retrospective review.²  The ³index visit² is the visit we sampled for review.
>> I won¹t get into all the details here, but this definition was used for a
>> study where we sampled primary care visits which preceded an unexpected
>> return visit to the primary care office or the ED.
>>  
>> So, when that definition is used we are pretty much eliminating the cases
>> that are evolving over time.  We called it a dx error when all the data was
>> there at the time of the visit to make the right dx.  As a practicing primary
>> care doc, I am very sensitive to the fact that diagnoses evolve over time and
>> it is often unclear what the dx is at the time of a single visit.  Our
>> research does not label delays when all the data is not available as an
>> error.
>>  
>> I agree with others that we will never know THE rate of diagnostic error.
>> However, with good measurement we can come to understand the frequency,
>> types, and contributing factors of dx error within certain practice settings
>> and for certain diseases.  I think a disease-specific and setting-specific
>> approach will lead to the most improvement.
>>  
>> While I have your attention (wishful thinking, I know) I¹d also say that we
>> are a very, very long way from measures of dx error that could be useful for
>> any external body (CMS, Leapfrog, etc) to use as some type of publically
>> reported performance measure.  Groups like that have already gone too far
>> with efforts to measure safety ­ in many organizations those externally
>> mandated, top-down measures create cultures of accountability and even blame
>> such that caregivers end up redefining or even hiding events so they don¹t
>> have to be reported to management.  Also, those externally mandated measures
>> only capture a small fraction of all the harm that occurs.  What we need,
>> especially for diagnostic errors, are cultures where learning and improvement
>> are valued.  Externally mandated measures, especially those not based on good
>> science, will not help us reduce diagnostic errors.
>>  
>> Best,
>>  
>> Eric
>>  
>> Eric J Thomas MD, MPH
>> Professor of Medicine
>> Associate Dean for Healthcare Quality
>> Director, UT Houston-Memorial Hermann Center for Healthcare Quality and
>> Safety
>> The University of Texas Medical School at Houston
>> 6410 Fannin UPB 1100.44
>> Houston, TX 77030
>> 713-500-7958
>> www.utpatientsafety.org <http://www.utpatientsafety.org/>
>>  
>>  
>>  
>> 
>> From: Pauker, Stephen [mailto:SPauker at TUFTSMEDICALCENTER.ORG]
>> Sent: Thursday, April 24, 2014 11:15 AM
>> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
>> Subject: Re: [IMPROVEDX] quick ?
>>  
>> 
>> Patient care and diagnoses evolve over time as things are revealed.
>> So labeling something as a diagnostic error depends on when in
>> the patient's course it's measured. In the course of disease evolution,
>> the primary diagnosis can change. So perhaps we should not make a diagnosis
>> ever but say "At this moment I think the probability of X is P". Of course,
>> the evolving issue is
>> when to treat or test with what modalities.
>>  
>> 
>> Steve
>>  
>> 
>> Stephen G. Pauker, MD, MACP, FACC, ABMH
>> Professor of Medicine and Psychiatry
>> ===========================
>> Please note new email address;
>> spauker at tuftsmedicalcenter.org
>> ===========================
>>  
>> 
>> 
>> From: Danny Long [mailto:dannylong at EARTHLINK.NET]
>> Sent: Thu 4/24/2014 8:42 AM
>> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
>> Subject: Re: [IMPROVEDX] quick ?
>> 
>> When cover-up is the standard of care, who really knows the facts besides the
>> ones doing the cover-up? The underlying motivation to nearly end autopsies..
>> just the truth.
>> Statistics
>> Errors related to missed or delayed diagnoses are a frequent cause of patient
>> harm. In 2003, a systematic review of 53 autopsy studies from 1966 to 2002
>> was undertaken to determine the rate at which autopsies detect important,
>> clinically missed diagnoses. Diagnostic error rates were 4.1% to 49.8% with a
>> median error rate of 23.5%.* Furthermore, approximately 4% of these cases
>> revealed lethal diagnostic errors for which a correct diagnosis coupled with
>> treatment could have averted death.4 Other autopsy studies have shown similar
>> rates of missed diagnoses; one study reported the rate to be between 10% to
>> 12%5, while another placed it at 14%.6 Autopsies are considered the gold
>> standard for definitive evidence of diagnostic error, but they are being
>> performed less frequently and provide only retrospective information.
>>  
>> 
>> http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2010/Sep7%283%29
>> /Pages/76.aspx
>>  
>> 
>> Knowing the CDC are well aware death certificates are often falsified... even
>> the Joint Commission are against autopsies .. so the prevailing logic is,
>> keep the facts blurry and the conversation of how bad is the problem will
>> keep the public in the dark. and make correcting the diagnosis problem nearly
>> impossible to do anything about.  = keep the excuses alive.
>>  
>> 
>>  
>> 
>> :-( garbage in garbage out to keep the data corrupt.
>>  
>> 
>> 
>> 
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