quick ?

Singh, Hardeep hardeeps at BCM.EDU
Sat Apr 26 16:16:07 UTC 2014


Colleagues,

To elaborate further on how we have tried to define diagnostic errors in our work,  feel free to review a recent editorial I wrote on Mark Graber et al's  paper in The Joint Commission Journal (March 2014:

Helping Health Care Organizations to Define Diagnostic Errors as Missed Opportunities in Diagnosis).



As Eric notes below, we still have work to do on improving reliability/validity and advancing the conceptual scientific knowledge in this area,  but perhaps some of these measurement concepts will be useful to others. Here is an except about definitions from the paper and it also has a diagram that might help clarify:



Although it’s tempting to assign responsibility

for a diagnostic error to a single clinician, research

suggests that the interplay of both system and cognitive contributory

factors is almost universal.3,9–11 Thus, in our work within

our multidisciplinary research group, we have shifted toward rebranding

diagnostic errors as “missed opportunities.” While our

research team continues to refine definitions and measurement,

we have found the following three criteria useful in defining diagnostic

errors3,8,12–14:

1. Case Analysis Reveals Evidence of a Missed Opportunity

to Make a Correct or Timely Diagnosis. The concept of a

missed opportunity implies that something different could have

been done to make the correct diagnosis earlier. The missed opportunity

may result from cognitive and/or system factors or

may be attributable to more blatant factors, such as lapses in accountability

or clear evidence of liability or negligence.

2. Missed Opportunity Is Framed Within the Context of an

“Evolving” Diagnostic Process. The determination of error depends

on the temporal or sequential context of events. Evidence

of omission (failure to do the right thing) or commission (doing

something wrong) exists at the particular point in time at which

the “error” occurred.

3. The Opportunity Could Be Missed by the Provider, Care

Team, System, and/or Patient. A preventable error or delay in

diagnosis may occur due to factors outside the clinician’s immediate

control or when a clinician’s performance is not contributory.This criterion suggests a system-centric versus physician centric approach to diagnostic error.



Reframing diagnostic errors as missed opportunities in diagnosis

could help shift attention and resources from attributing

blame to learning from these scenarios.


Best,
Hardeep




________________________________
From: David Gordon, M.D. [davidc.gordon at DUKE.EDU]
Sent: Friday, April 25, 2014 12:11 PM
Subject: Re: 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 intended only for the addressee(s). Any other person, including anyone who believes he/she might have received it due to an addressing error, is requested to notify the sender immediately by return electronic mail, and to delete it without further reading or retention. The information is not to be 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, “An 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.”  The “index visit” is the visit we sampled for review.  I won’t 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) I’d 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 don’t 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<mailto: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<mailto: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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