In Search of a Common Definition of Dx Error

Bruno, Michael mbruno at HMC.PSU.EDU
Mon May 9 15:52:38 UTC 2016

Very important point!  Thanks, Peter!


Being wrong feels exactly the same as being right. Which is why we need systems to help us identify when we are wrong, so we can correct things before the universe intervenes.

From: Elias Peter [mailto:pheski69 at GMAIL.COM]
Sent: Sunday, May 08, 2016 9:19 PM
Subject: Re: [IMPROVEDX] In Search of a Common Definition of Dx Error

Interesting, and you did far better than I would have, I think. Obviously, though, this is not a measure of errors.

Kathryn Schulz makes a great and important point about this in her excellent TED talk about being wrong (link below).

She asks the audience how it feels to be wrong and gets lots of answers: humiliating, shameful, dreadful, thumbs down.  She points out that these are answers to the question: how does it feel to realize you are wrong.

Being wrong feels exactly the same as being right. Which is why we need systems to help us identify when we are wrong, so we can correct things before the universe intervenes.

Peter Elias


On 2016.05.08, at 9:01 PM, robert bell <rmsbell200 at YAHOO.COM<mailto:rmsbell200 at YAHOO.COM>> wrote:

For a talk on Errors I did a test on myself to find out how many “errors" I made in 2 days. I defined an error as something that “minimally annoyed” me.

Such as Jumping into the car in the garage but having left the mail in the house, or forgetting to call someone despite making a note to myself, or tripping on a step

I had 8 one day and 6 the next.

I did not attempt to diagnose what caused the error!

Rob Bell

On May 8, 2016, at 4:33 PM, Elias Peter <pheski69 at GMAIL.COM<mailto:pheski69 at GMAIL.COM>> wrote:

Excellent addition to Ruth’s excellent discussion.

One big problem: a record keeping system that is basically a billing system decorated with medical add-ons and requires that we pick a diagnosis from a pre-defined list of billable options seems a barrier to (if not actually incompatible with) a thoughtful process of differential diagnostic reasoning or a goal of a tentative working assessment.

When I pick a ‘diagnosis’ from the options in the EHR, I hear a voice in the back of my mind saying: “Is that your final answer?” That voice in the back of my mind should be asking me Charlie’s questions.


On 2016.05.08, at 1:47 PM, Charlie Garland - The Innovation Outlet <cgarland at INNOVATIONOUTLET.BIZ<mailto:cgarland at INNOVATIONOUTLET.BIZ>> wrote:

Ruth, I would propose, at a minimum, adding one more dimension to the definitions offered in the set you've compiled.  And that is the concept of a "complete" diagnosis.  The reason for this is specifically to address what is thought to be among the major causes of Dx error: cognitive bias.  In fact, using a list of cognitive biases to help inform our analysis of an improved definition is probably a good idea (I'm sure many on this thread would agree), assuming we'd like such a definition to help clinicians to reflect upon that definition, and to help provider Quality personnel assess best practices, in the quest to reduce Dx errors.

Consider that a Dx can be accurate and timely, but still not be complete.  How might this occur?  Simply because a clinician identifies an accurate assessment of the cause of a patient's symptoms, and documents/reports it on time, but still fails to ask the "WHAT ELSE" (and related) questions at crucial points throughout the patient engagement process.  These might include the many non-standard questions which could be asked upon taking patient history (both of the patient and of others who may know that patient, e.g. family caregivers), upon examining the patient, upon reviewing any number of lab/test results, and so on.  This is meant to address not only incidentalomas and/or comorbidities, but also undiagnosed root causes of the symptoms, some of which may not yet have manifest.

One may respond to this recommendation with "well, you're simply describing one form of a missed diagnosis!" And perhaps they'd be technically correct; however, that correctness does not necessarily help a clinician to change his/her behavior -- by at least contemplating the many "-ELSE?" questions that will likely uncover important information that might otherwise be missed (just a small sample of such):

  *   What else...might be going on here?  What else...could be causing these symptoms?  What other illnesses are likely, given the information/causes we do know about at this point?
  *   Where else...might I find evidence of other mechanisms at play?  Where else (e.g. on the MRI) should I be focusing?
  *   Who else...might be a source of insight upon this patient than the patient him/herself, or other than myself?
  *   How else...might these symptoms have been caused or influenced?
  *   Why else...might this patient not be telling me every other bit of info that is relevant to my Dx?  What are his/her fears, (conscious) assumptions, (unconscious) presumptions, or biases?  What are mine?
  *   When else...might these symptoms have shown up before?  When the past might there be information that would more appropriately inform my decisions?
The above is not meant at all to be an exahaustive list -- merely a brief sampling.  The "Cubie" logic model that we use is intended explicitly to be a thinking guide (and a trigger) to such "Explorative Inquiry" that is designed to help elicit additional, valuable information that improves clinician perspective.

Thank you,
Charlie G.


Charlie Garland, Senior Fellow of HITLAB<> (Healthcare Innovation & Technology Laboratory @ Columbia University Medical Center)

office:  212.535.5385
mobile: 646.872.0256

Designer of The Innovation Cube<> (a.k.a. CubieTM - a Critical Thinking & Creative Problem-Solving Tool)
Developer of Cognitive Buoyancy<> (a construct of model, method, and metric: "The Trigger to Innovation")

Twitter: @innovationator<>

-------- Original Message --------
Subject: [IMPROVEDX] In Search of a Common Definition of Dx Error
From: Ruth Ryan <ruthryan at COX.NET<mailto:ruthryan at COX.NET>>
Date: Thu, May 05, 2016 3:23 pm
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?



Source or Citation


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.


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