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

Pat Croskerry croskerry at EASTLINK.CA
Thu Aug 21 21:30:48 UTC 2014


Bimal: good points.
Often in clinical medicine the issue seems to come down to separating the
signal from the noise - great work on this topic was done by Swets and
Tanner many years ago.
There is a continuum of 'manifestness' along which all diseases present. The
highly manifest (pathognomonic) are at one end, and the least manifest
(woolly/indistinct) at the other. For the former the signal-noise curves are
almost completely distinct from each other, whereas for the latter they may
overlap completely. Research studies often focus on the manifest
presentations which is a distortion of clinical experience. Diagnostic
acumen seems to require an ability to effectively separate signal from noise
with minimal effort.
The two main biases involved here are 'Representativeness' (looking for
characteristics that conform to a typical member of the group, and
'Ascertainment bias' (seeing what you expect to see) which is not quite the
same thing.
ROWS (rule out worst case scenario) is a strategy that emergency physicians
often use to avoid the charge of neglecting the base rate.
Pat 



-----Original Message-----
From: Jain, Bimal P.,M.D. [mailto:BJAIN at PARTNERS.ORG] 
Sent: Thursday, August 21, 2014 7:49 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]
Sent: Tuesday, August 19, 2014 10:01 AM
To: 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 rryan at lammico.com
Telephone (504) 841-2736
Fax (504) 841-5312


-----Original Message-----
From: Jeffery Anderson [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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