Diagnostic Error as Major Issue in Healthcare reported in ECRI and ASHRM Today

Art Papier apapier at LOGICALIMAGES.COM
Thu Aug 21 13:40:44 UTC 2014


Bimal, This is a great comment on variation.  We too often focus on the
"rare birds" instead of diagnostic error due to variants of common disease.
We teach medical students about pemphigus vulgaris (see a new patient with
pemphigus about once every 10 years) but for example how often do we insure
that primary care physicians understand the variations of herpes simplex.
Practicing in a rural community I had a patient treated with Keflex about 6
times over 3-4 years for grouped vesicles on the palm.  The PCP thought it
was bacterial.  The PCP was likely trained to look for herpes on the lips
and genitals, and did not see the pattern of the grouped vesicles because of
the thickness of the stratum corneum of the palm, making it difficult to see
the lesions as vesicles.    Also had probably been taught that herpes does
not occur anywhere which it can.  In the same community months later I had a
hospital consult for an OB patient with grouped vesicles on the thigh in the
same community, obvious herpes simplex, but the hospitalist and attending
could not diagnose it.   This is anecdotal, but I can tell you that all
dermatologists worldwide are gritting their teeth about the crazy number of
"bilateral cellulitis" consults for obvious stasis dermatitis, and host of
other repeatable diagnostic mistakes of common presentations.

In our work we have been systematically collecting cases of disease
presenting with skin, eye, oral mucosal, hair and nail findings for 15
years.  We have over 100,000 images that are systematically catalogued and
obtained from leading institutions and experts.  If you look through an
expansive set of images for a disease, you can easily see variants that are
simply not in the text books.  For instance a fixed drug eruption presents
most typically with a single or few round patches on the genitals or face or
perhaps an extremity.  A known variant is bullous fixed drug eruption.  The
cases we have systematically collected show many fixed drug eruptions
localizing to the web spaces of the hand. Having had the  I had a patient
with a lesion in the web spaces treated with lotrimin and other antifungals
and it was fixed drug.  We teach to the classic and then we expect
clinicians to generalize to the variants.  It seems to be a flawed premise.
from  a cost perspective, my hunch is that the volume of error around
variants of common dwarfs the missed rare birds.  Art

 

http://scomber:8080/resizeimage?ImagePath=/ImageArchive/81166-81176/81171.jp
g&Fit=1&Height=600&Width=800&Quality=.75&ScaleMethod=SCALE_AREA_AVERAGING

 

Art Papier, MD

Chief Executive Officer

585.272.2630 | apapier at logicalimages.com

______________________________

 

www.visualdx.com

 

 

-----Original Message-----
From: Jain, Bimal P.,M.D. [mailto:BJAIN at PARTNERS.ORG] 
Sent: Thursday, August 21, 2014 6:49 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] Diagnostic Error as Major Issue in Healthcare
reported in ECRI and ASHRM Today

 

I did not have a chance to comment during John Ely's interesting webinar
yesterday as I joined in by telephone. Here are my thoughts about his
important study.

1. A major reason for failure to broaden differential diagnosis may be our
lack of awareness of the wide variation in clinical presentations of a given
disease ranging from highly typical to highly atypical in different
patients. This may be due to medical school and textbook teaching which
focuses primarily on typical presentations of a disease. Awareness of
variation could be increased, I suggest, by looking at summaries of
presentations in about one hundred consecutive patients with a given disease
seen at a large medical institution. These summaries could be stored in a
computer file which could be made available to all interested physicians.

 

2. An atypical presentation is often interpreted as low pretest evidence due
to low pretest probability of a disease which may be ruled out without
further testing. I believe, a presentation should be looked upon as a clue
to a disease and not pretest evidence which should be ruled in or out by
further testing. This would avoid premature closure.

 

3. The rule of not neglecting base rate is a statistical rule which may not
apply in a given, individual patient as we saw in the patient found to have
neurosyphilis. I believe it is all right to break this rule by suspecting a
rare disease if all other suspected diseases are found not to be present.

 

4. There is so lttle we know about how diagnosis is performed in actual
practice or should be performed to minimize diagnostic errors. I would like
to thank John Ely and other investigators who have started to look at
diagnosis in actual practice and increase our understanding of this
important process.

 

All the best,

 

Bimal

 

Bimal P Jain MD

Pulmonary-Critical Care

NorthShore Medical Center

Lynn MA 01904

 

-----Original Message-----

From: Ruth Ryan [ <mailto:rryan at LAMMICO.COM> mailto:rryan at LAMMICO.COM]

Sent: Tuesday, August 19, 2014 10:01 AM

To:  <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG

Subject: Re: [IMPROVEDX] Diagnostic Error as Major Issue in Healthcare
reported in ECRI and ASHRM Today

 

Bravo and hats off to you, Jeffery!  If critical thinking skills can be
built into the community college program training paramedics in Bossier
Parish, North Louisiana, never let it be said such training is ethereal, too
difficult, or relevant only to the ivory tower.

 

Ruth

Ruth Ryan RN, BSN, MSW, CPHRM

Senior Risk Management Education Specialist LAMMICO

1 Galleria Blvd., Suite 700

Metairie, LA 70001

E-Mail  <mailto:rryan at lammico.com> rryan at lammico.com

Telephone (504) 841-2736

Fax (504) 841-5312

 

 

-----Original Message-----

From: Jeffery Anderson [ <mailto:janderson at BPCC.EDU>
mailto:janderson at BPCC.EDU]

Sent: Sunday, August 17, 2014 9:26 PM

Subject: Re: Diagnostic Error as Major Issue in Healthcare reported in ECRI
and ASHRM Today

 

I am developing a module on critical thinking for my paramedic program.
Besides using Dr. Croskerry's articles and information from the Foundation
for Critical Thinking, I am also using the textbook Patient Safety in
Emergency Medicine by Croskerry and Emergency Medicine Decision Making by
Weingart as references.  In addition I have been following the work of Dr.
Kevin deLaplante of the Critical Thinker Academy.

 

Jeffery D. Anderson, NREMT-P

Paramedic Program Director

Bossier Parish Community College

Office Phone (318) 678-6403

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