In Search of a Common Definition of Dx Error

Elias Peter pheski69 at GMAIL.COM
Fri May 6 17:10:34 UTC 2016


This pushed my buttons, a bit. I may not know how many errors are committed or how many patients are harmed by preventable errors in the sense of a number.  That is unfortunate, and I wish we had a better (more fact-based) understanding. What I know that it is too many, and that arguing about the data instead of using the data gets us nowhere.

I agree that the estimated level of error is just that, an estimate. But let’s not fool ourselves:

Physicians in all specialities are presumably practicing evidence-based medicine? Much (perhaps even most?) of what we do in medicine is lacking a basis in evidence, or based on extrapolation (estimates, if you will) from partial, conflicting, outdated, and often incorrect evidence.
Even when we have what we think is good evidence, it is good evidence for a population that at best is only similar to a given individual patient, and we have to extrapolate (estimate, if you will) how it applies (or not) to the individual patient in the room with us, and then we have to make a decision about what to do.
We (clinicians and policy makers) like to pretend (to ourselves and the public) that our estimates of what is best care are far more evidence based, durable, reliable and applicable than is really the case. The word ‘estimating’ does not occur very often when we are talking to patients: “I would estimate that, based on some statistical projections, you are more likely to be helped than harmed by X.”  Nope. We tell our patients: “You have X. The treatment is Y.”  Or, if we are into SDM, we might say:  “You have X. The treatment options are Y and Z.” If we are trying to be very honest about what we know, we might say: “You have X. The treatment options are Y and Z . The evidence tells us that Y has this results and Z has this results.” We don’t very often admit to ourselves or our patients that the evidence is shaky and we are guessing.

My point is: in medicine is do the best we can with the best information available. We need to do the same with this issue, and not let the uncertainty distract us from admitting we have a problem and working on solutions.

The fact that we know so little about the harms we cause is not something to be proud of. We certainly dare not use our uncertainty as an excuse to pretend we know nothing about how much harm we cause. We wouldn’t take that approach to cancer or Zika. We would use what we have to do the best we can and work hard to get better information.

I’m imagining the amusement ride industry (I’m tired of the airline analogy) saying, after an article is published calling attention to a large number of injuries and deaths from poorly maintained rides: “We don’t know how many children are harmed or killed by poor maintenance of rides and we will never know, but we assure you that we are working to make rides safer." I wouldn’t find that statement either credible or reassuring.  I would want the amusement ride industry to admit that there is a problem and be transparent about how it inspects, who does the inspections, how often, what the results are, how they are working to improve the inspection system, what they are doing with the results, and what the ride owners and operators do with the results. 

Peter



> On 2016.05.06, at 10:55 AM, Leonard Berlin <lberlin at LIVE.COM> wrote:
> 
> Over the past several days I have enjoyed reading the long list of commentaries submitted by very bright and caring physicians.  medical-associated people,  and researchers,  on the subject of the frequency of medical errors and their  role in causing death of patients. This has led me to conclude the following undeniable fact: 
>  
>  NOBODY KNOWS HOW MANY MEDICAL ERRORS ARE COMMITTED, AND NOBODY KNOWS HOW MANY PEOPLE ARE KILLED BY MEDICAL ERRORS!
>  
> The articles by Makary and others that calculate numbers related to medical errors and patient injury are nothing more than statistical projections,  extrapolations, estimates, and conjectures.  
>  
> Makary, Johns Hopkins, and the BMJ got great international headlines by "estimating" that 251,454 patients die of medical mistakes annually. Needless to say, the word "estimating" doesn't appear very much,  if at all, in the headlines and limited text proclaimed  in newspaper and TV news reports.  
>  
> Today, physicians  in all specialties are presumably  practicing   "evidence-based-medicine."  
>  
> When it comes to medical errors, there is no "evidence!"
>  
> Yes, focusing attention on medical errors is certainly productive, and indeed encourages all of us to improve medical care safety and reduce errors.  And clearly, supporting organizations such as  SIDM is a step in the right direction.
>  
> We should be transparent to the public, but frightening everyone and causing them to lose confidence in their physicians is counterproductive. Our message to the public should be an honest one:  MEDICAL ERRORS DO OCCUR, BUT WE DO NOT KNOW, AND WILL NEVER KNOW, HOW MANY PATIENTS DIE DUE TO A MEDICAL ERROR; HOWEVER, WE ARE WORKING ON WAYS TO REDUCE THEM.
>  
> Lenny
> Date: Thu, 5 May 2016 14:23:22 -0500
> From: ruthryan at COX.NET
> Subject: [IMPROVEDX] In Search of a Common Definition of Dx Error
> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> 
> To all, 
>  
> Allow me to pick the finest brains on this topic.  Should SIDM adopt one of these definitions below, or craft a combination of these elements?  How would you define it?
>  
> DEFINITIONS OF DIAGNOSTIC ERROR
>  
> Author
> Source or Citation
> Definition
> Mark Graber
> Diagnostic errors in medicine: a case of neglect. Jt Comm J Qual Patient Saf. 2005.
>  
> Graber ML, Franklin N, Gordon R. Diagnostic error in internal medicine. Arch Intern Med. 2005
> Medical diagnoses that are wrong, missed, or delayed.
>  
> A diagnosis that was unintentionally delayed (sufficient information was available earlier), wrong (another diagnosis was made before the correct one), or missed (no diagnosis was ever made), as judged from the eventual appreciation of more definitive information.
>  
> Hardeep Singh
>  
> Helping healthcare organizations to define diagnostic errors as opportunities in diagnosis. Jt Comm J Patient Safety, 2014.
>  
> A breakdown in the diagnostic process and a missed opportunity to have made the diagnosis more accurately or more efficiently…regardless of whether there was patient harm.
> Gordon Schiff et al
> Schiff GD, Hasan O, Kim S, Abrams R, Cosby K, Lambert BL, et al. Diagnostic Error in Medicine: Analysis of 583 Physician-Reported Errors. Arch Intern Med. 2009
> Any mistake or failure in the diagnostic process leading to a misdiagnosis, a missed diagnosis, or a delayed diagnosis. This could include any failure in timely access to care; elicitation or interpretation of symptoms, signs, or laboratory results; formulation and weighing of differential diagnosis; and timely follow-up and specialty referral or evaluation.
>  
> Institute of Medicine
> Improving Diagnosis in Health Care, 2015 report Institute of Medicine (IOM)
> The failure to establish an accurate and timely explanation of the patient's health problem(s) or to communicate that explanation to the patient.
>  
>  
> BEST DEFINITION OR COMBINED DEFINITION:
>  
> Fill in the blank
>  
>  
>  
> Ruth
>  
> Ruth Ryan RN, BSN, MSW, CPHRM
> Medical writer
> Risk management/patient safety
> Continuing medical education
> Telephone (504) 256-8797
> Email ruthryan at cox.net <mailto:ruthryan at cox.net>
> <image001.jpg>
>  
>  
> 
> 
> 
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> 
> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in Medicine
> 
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> 







Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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