quick ?

Gerrit Jager gerrit.jager at PLANET.NL
Mon Apr 28 22:16:56 UTC 2014


I fully agree with John,

I prefer to focus on educating excellent diagnosticians, however in relation
to diagnostic errors this may ambiguous

 In the discussion a diagnostic error was defined as a missed opportunity.
Compare it to golf. If I have to make a put over 20 meters it is ³mission
impossible², however for a professional player it is an ³opportunity².  So
the better you are the more opportunities, and perhaps the more missed
opportunities.

I still understand the need to measure diagnostic errors and I support the
efforts, but at the moment I expect future articles with the title: ³The
Quality of Measuring Diagnostic Errors²

Gerrit

Gerrit Jager

Radiologist
The Netherlands

Op 27-04-14 19:40, John Brush <jebrush at ME.COM> schreef:

> I have been following this conversation and I continue to believe that our
> best way to improve diagnosis in medicine is to teach good habits. Teach
> people to be systematic, to appropriately use the available tools, and to
> calibrate their intuitive approaches with better numerical literacy and
> probability estimates.  Focusing on errors doesn¹t seem like a very fruitful
> path forward.
> Anecdotes and patient stories can motivate us to improve, but don¹t
> necessarily give us the lessons on how to improve. And measuring diagnostic
> error rates will always be difficult in the real world. No doubt, the studies
> that have estimated the error rates are important for raising public awareness
> and motivating our efforts. Diagnostic errors occur way too commonly. But
> measuring diagnostic error rates will be always be problematic for analysis of
> individual performance over time. Effective practitioners seek follow up,
> measurement and feedback for internal use, but external reporting of error
> rates could have lots of unintended consequences.
> Measuring diagnostic skill is like measuring fielding in baseball. Baseball
> uses fielding percentages, but we know that that measure is flawed. A player
> can improve his fielding percentage by limiting his range. Likewise, a
> hospitalist can lower his/her error rate by consulting on every patient and
> ordering lots of tests, which in effect limits his/her range and is very
> inefficient. And certain positions, like first base, have a better chance of
> getting a higher fielding percentage. Likewise, certain medical specialties
> have a better chance of avoiding diagnostic error than others. Also, to
> measure fielding percentage, you have to track every single opportunity, which
> is virtually impossible in clinical medicine. This email string is a testament
> to the difficulties in defining errors and tracking opportunities.
> So, in my humble opinion, we need to focus on education efforts, to help
> practitioners and patients develop better diagnostic habits, and facilitate
> the consistent use of these good habits.
> John
> 
> John E. Brush, Jr., M.D., FACC
> Professor of Medicine
> Eastern Virginia Medical School
> Sentara Cardiology Specialists
> 844 Kempsville Road, Suite 204
> Norfolk, VA 23502
> 757-261-0700
> Cell: 757-477-1990
> jebrush at me.com
> 
> 
> 
> On Apr 26, 2014, at 12:30 PM, Pauker, Stephen <SPauker at tuftsmedicalcenter.org>
> wrote:
> 
> Re: [IMPROVEDX] quick ?
> Let me extend Kassirer's thought perhaps. Allow me to suggest, depending on
> definitions, that our quest for being free of diagnostic errors is similarly
> stubborn and may sometimes be unattainable, when diagnostic uncertainty still
> exists at a given point of time
> Steve
> 
> 
> 
> Sent with Good (www.good.com <http://www.good.com> )
> 
> 
> -----Original Message-----
> From: Gerrit Jager [gerrit.jager at PLANET.NL]
> Sent: Saturday, April 26, 2014 11:11 AM Eastern Standard Time
> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> Subject: Re: [IMPROVEDX] quick ?
> 
> 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
> <x-msg://15/rmsbell@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
>> <x-msg://15/EHOFFER@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
>>> <x-msg://15/davidc.gordon@DUKE.EDU> ]
>>> Sent: Friday, April 25, 2014 1:11 PM
>>> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
>>> <x-msg://15/IMPROVEDX@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
>>> 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
>>> <x-msg://15/MITTAL@EMAIL.CHOP.EDU> ]
>>> Sent: Friday, April 25, 2014 10:50 AM
>>> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
>>> <x-msg://15/IMPROVEDX@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
>>> <x-msg://15/Eric.Thomas@UTH.TMC.EDU> ]
>>> Sent: Friday, April 25, 2014 9:51 AM
>>> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
>>> <x-msg://15/IMPROVEDX@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
>>> <mailto:SPauker at TUFTSMEDICALCENTER.ORG> ]
>>> Sent: Thursday, April 24, 2014 11:15 AM
>>> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
>>> <x-msg://15/IMPROVEDX@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 <x-msg://15/spauker@tuftsmedicalcenter.org>
>>> ===========================
>>> 
>>> 
>>> 
>>> 
>>> From: Danny Long [mailto:dannylong at EARTHLINK.NET
>>> <mailto:dannylong at EARTHLINK.NET> ]
>>> Sent: Thu 4/24/2014 8:42 AM
>>> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
>>> <x-msg://15/IMPROVEDX@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%2
>>> 9/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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>> 
>> 
>> 
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