quick ?

Xavier Prida dr.xavier.prida at GMAIL.COM
Sat Apr 26 20:38:41 UTC 2014


Hardeep,

In our system, we have similarly derived, albeit, a more simplistic
taxonomy of "missed opportunities":

1.) Cognitive- "I didn't know that"(knowledge deficit)- where lists or
decision matrices may assist

2.) Interpretive- " I didn't see that"( ST elevation on ECG, nodule on
plain CXR, etc.)- over reads, computer
interpretation algorithms

3.) System- Something occurred that should not have, or did not occur that
should have(neither under direct                          control of any
one clinician)

Within each of these domains, then, a structure or process gap can be
identified which may or may not have a clinician attribution, in whole or
in part(by clinician is meant any person in the care path).

What are your thoughts?



On Sat, Apr 26, 2014 at 12:16 PM, Singh, Hardeep <hardeeps at bcm.edu> wrote:

>  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
>
> errors
> 3,8,12–14:
>
> * 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
>
>
>
>
>
>
>
> *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<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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-- 
Xavier E. Prida MD FACC FSCAI
813 813 0721(H)
813 245 3143(C)








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