Definition of Diagnosis Error

Peggy Zuckerman peggyzuckerman at GMAIL.COM
Thu Jan 19 23:17:52 UTC 2017


As a patient and as a member of the Patient Engagement Committee, I would
recommend that this discussion continue, but emphasize in all aspects that
the need to communicate the diagnosis to the patient in a meaningful way
should be seen as the easiest element to incorporate into the system.  For
example, if the patient receives all his reports, imaging, lab, follow-up,
doctor's notes, etc, there is immediately a greater chance for the party
most impacted to become part of the team.  As a minimum, the patient can
certainly see if he is correctly identified--not confused with his uncle
with a similar name, or his severe penicillin allergy not recorded.
Studies show that 15% of medical records have basic identification errors.

Patients are also more likely to read the entire radiology report, even
down to the unexpected findings.  Too often, a finding which is expected
becomes confirmatory, yet the unanticipated finding is more important.
Cancer patients, once able to receive those reports, can often find mention
of a lesion which is not given proper monitoring or follow up.  Sadly, some
patients are indeed diagnosed, thanks to this kind of imaging, and clearly
indicated in the report language--yet never receive this info.

Then there is the possibility that the patient will have a greater
understanding of the diagnosis, or the ongoing diagnostic process, so that
he can work more closely with the doctors, anticipate the treatment and do
some degree of self-monitoring.

Low-hanging fruit compared to some of the complexity under discussion, but
with great impact for all.

Peggy Zuckerman

Peggy Zuckerman
www.peggyRCC.com

On Thu, Jan 19, 2017 at 2:07 PM, Bob Latino <blatino at reliability.com> wrote:

> I believe it safe to say, it is more plausible to start with what is
> known, before addressing what is unknown. This seems to be the fastest way
> to reduce the impact to the patient.
>
>
> I am just trying to get a grasp of a starting point for this group.
> Perhaps I am not aware of ongoing, macro efforts by this group to getting a
> hold on the scope and magnitude of the problem?
>
>
> In my world, the Dx Error is not the problem, it is a cause category.  An
> undesirable outcome has to result, as a result of a Dx Error related
> issue.  An undesirable outcome could be death, harm, near miss or high
> risk.  Initially we would be less concerned with Dx Errors where these
> outcomes did not occur (or were not known at all).
>
>
> Off the top, wouldn't we be most concerned with the known Dx Error cases
> that resulted in death and/or harm?  From an analytical standpoint,
> wouldn't that be a good starting point to collect data and then try to sort
> the causes of these Dx cases into manageable and definitive sub-categories?
>
>
> Where is the starting point to formulate a plan to act on for this massive
> issue?
>
> Once again, thanks for your patience with this outsider who has an
> annoying, 'questioning attitude'.
> ------------------------------
> *From:* Koppel, Ross J <rkoppel at SAS.UPENN.EDU>
> *Sent:* Thursday, January 19, 2017 3:11 PM
>
> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> *Subject:* Re: [IMPROVEDX] Definition of Diagnosis Error
>
> May I add that in so many cases we never ever realize there was an error.
> Patients get better...die...something else become more prominent... we need
> to focus on the effects of the meds...hidden by polypharmacy...by age....etc
>
>
>
>
> Ross Koppel, PhD, FACMI
> Sociology Dept,
> LDI Senior Fellow, Wharton
> Affiliate Faculty, Medical School
> UNIVERSITY OF PENNSYLVANIA
> Rkoppel at sas.penn.edu
> Also, Prof of Biomedical Informatics
>  SUNY Buffalo
>
>
> -------- Original message --------
> From: "Ely, John" <john-ely at UIOWA.EDU>
> Date: 1/19/17 1:44 PM (GMT-05:00)
> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> Subject: Re: [IMPROVEDX] Definition of Diagnosis Error
>
> Rather than trying to define diagnostic error in a single sentence I think
> we should focus on the dimensions of diagnostic error and there are a lot
> of dimensions.  I agree with David that diagnostic error has a “truly
> massive scope” that is probably too massive to allow a one-sentence
> definition.  I also agree that the IOM definition is probably the best
> effort at a one-sentence definition, but only the first half.  The second
> half is an important problem.  A life-threatening problem.  But it’s not a
> diagnostic error.  It’s a communication error.  An extremely important
> communication error, but including it in the definition confuses the
> fundamental meaning of diagnostic error. Here are some of the dimensions:
>
>
>
> 1.  Do we want a conceptual definition or an operational definition?  If
> you do research, you need an operational definition.
>
> 2.  Should we define diagnostic error according to what it is (Graber,
> Singh, Schiff:  missed, delayed, wrong, missed opportunity, wrong process)
> or according to what it is not (IOM: failure to establish an accurate and
> timely diagnosis).
>
> 3.  Was there fault (i.e., missed opportunity) or no fault?
>
> 4.  If there was fault, were there mitigating circumstances (difficult
> diagnosis, difficult patient, difficult environment, new disease (HIV in
> the early 80’s, first cases of Legionnaires))?
>
> 5.  If there was fault, whose fault was it (physician, patient, NIH for
> not funding research on better tests or diagnostic strategies, hospital
> administrator who failed to adequately staff the emergency room or buy
> better diagnostic equipment)?
>
> 6.  If there was fault, who determined that there was fault and how did
> they determine it?
>
> 7.  Was it a near miss and what are the different kinds of near misses?
>
> 8.  Was it overdiagnosis and what are the kinds of overdiagnosis?
>
> 9.  What does timely mean as in “timely diagnosis”?
>
> 10.  What is the seriousness of the error (from trivial to serious)?  When
> we talk about diagnostic errors, we only think of the devastating ones, but
> most are trivial and occur every day in everyone’s practice (Pareto
> Principle).
>
> 11.  What is the seriousness of the patient harm (from nonexistent to
> death)?  You can have serious errors that are associated with zero patient
> harm, or even patient benefit.
>
> 12.  How do screening errors relate to diagnostic error?
>
> 13.  How do we decide if it was an error?
>
> 14.  What about errors that benefit the patient (e.g., failing to diagnose
> breast cancer or prostate cancer in which the treatment is worse than the
> disease)?
>
> 15.  How to detect and measure errors?  Can we measure errors without
> defining them?
>
> 16.  What causes diagnostic errors?
>
> 17.  How can we prevent diagnostic errors?
>
> 18.  What is the opposite of diagnostic error?
>
> 19.  What is our certainty about the correct diagnosis (definitive test,
> patient course, autopsy diagnosis, surgical diagnosis)?  All of these could
> be wrong and even if we never have anything definitive, there is still a
> correct diagnosis out there (what God knows)?
>
> 20.  Response to error (e.g., apology, root cause analysis, malpractice
> suit, forgiveness)
>
> 21.  Communication problems (physician-patient, physician-physician,
> physician-nurse)
>
> 22.  Treatment issues as they relate to the diagnostic process.  Treatment
> issues as they relate to diagnostic error.
>
> 23.  Whose perspective are we using when trying to define diagnostic
> error?  Patient, physician, lawyer, nurse, administrator, researcher?
>
>
>
> And there are many other dimensions and subcategories of these.  I think
> it would be useful to develop a taxonomy of these dimensions and illustrate
> how they are interrelated.  It would help us pigeon hole the causes,
> interventions, research, journal articles, discussions, etc.  We could
> organize our efforts and prioritize them using the taxonomy.  I have
> started to work on this.  I have lots of categories and subcategories.  I’m
> up to 6 pages so far.  But it needs input from others.  (Let me know if
> interested.)
>
>
>
> John Ely, MD
>
> University of Iowa
>
>
>
>
>
> *From:* David Newman-Toker [mailto:toker at JHU.EDU]
> *Sent:* Thursday, January 19, 2017 8:37 AM
> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> *Subject:* Re: [IMPROVEDX] Definition of Diagnosis Error
>
>
>
> Your logic is totally appropriate, but the availability of data does not
> allow us to achieve the level of precision (yet) that I suspect you desire.
>
> The IOM/NAM definition is of a problem with truly massive scope, although
> that scope is, as yet, not defined with much precision. We suspect there
> are at least 12 million such errors each year in the US… possibly more.
>
> Serious harms (disability/death) probably affect hundreds of thousands.
> The parts of that problem that are worth solving and can be solved in the
> relatively near future are smaller in scope.
>
> In my view, it is easier to have the larger superset of these problems be
> bigger, rather than smaller, and for the individual problems to be true
> subsets.
>
> There are many of us seeking to break the problem into bite-size chunks,
> and to measure those chunks (and eventually the larger problem), more
> systematically.
>
> If we all keep working in that direction, eventually we will get there. In
> the meantime, we need some “early wins” on a manageable subset so that
> people can see this as a tractable problem.
>
> David
>
>
>
>
>
>
>
> *David E. Newman-Toker, MD PhD*
> Professor of Neurology, Ophthalmology, & Otolaryngology
>
>
>
> *Director, Division of Neuro-Visual & Vestibular Disorders*
>
>
> *http://www.hopkinsmedicine.org/neurology_neurosurgery/centers_clinics/vestibular/team/*
> <http://www.hopkinsmedicine.org/neurology_neurosurgery/centers_clinics/vestibular/team/>
>
>
>
> *Director, Armstrong Institute Center for Diagnostic Excellence*
>
>
> *http://www.hopkinsmedicine.org/armstrong_institute/center_for_diagnostic_excellence/*
> <http://www.hopkinsmedicine.org/armstrong_institute/center_for_diagnostic_excellence/>
>
>
>
> Johns Hopkins University School of Medicine
> Johns Hopkins Hospital; CRB-II, Room 2M-03 North
>
> 1550 Orleans Street; Baltimore, MD 21231
>
> Email: toker at jhu.edu
>
>
>
> Administrator: Doug Montague (410) 955-2536; dmontag6 at jhu.edu
>
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> Confidentiality Notice: The information contained in this email is
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>
>
>
> *From:* Bob Latino [mailto:blatino at reliability.com
> <blatino at reliability.com>]
> *Sent:* Thursday, January 19, 2017 9:27 AM
> *To:* David Newman-Toker <toker at jhu.edu>; Society to Improve Diagnosis in
> Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
> *Subject:* RE: [IMPROVEDX] Definition of Diagnosis Error
>
>
>
> My purpose is seeking clarification is because I don't see unity in
> purpose within the various Diagnosis Error communities, on a common
> definition.  If the problem cannot be uniformly defined, how can it be
> solved?  In order to solve such a massive issue, there has to be an
> identified scope of the problem.  To me, these definitions vary widely in
> scope.  If I can't determine scope, I can't determine magnitude of the
> problem.
>
>
>
> I see many, many discussions about proposed solutions, but I have not seen
> much about breaking the 'problem' down into its manageable components, and
> determining systemic causes that are actionable.
>
>
>
> I'm from the investigative community and just trying to look at how this
> Community is going about identifying the specific root causes of diagnosis
> error and acting on those evidence-based deficiencies?
>
>
>
> I am not from the clinical community, so my interest is in just seeing
> what reasoning process/pattern is being used to methodically solve this
> problem, that affects every user of the U.S. healthcare system.
>
>
>
> I am just a lurker and certainly not an SME like the majority of
> participants on this forum.  I am just trying to keep up with the
> conversation:-)
>
>
>
> Thanks for your patience with my questions.
>
>
>
> *Robert J. Latino, CEO*
>
> Reliability Center, Inc.
>
> 1.800.457.0645 <(800)%20457-0645>
>
> blatino at reliability.com
>
> www.reliability.com
>
> [image: linkedin logo signature file]
> <https://www.linkedin.com/company/958495?trk=tyah&trkInfo=clickedVertical%3Acompany%2CclickedEntityId%3A958495%2Cidx%3A1-1-1%2CtarId%3A1464096807851%2Ctas%3Areliability%20center%2C%20inc.>
>
>
>
> *From:* David Newman-Toker [mailto:toker at jhu.edu <toker at jhu.edu>]
> *Sent:* Thursday, January 19, 2017 9:07 AM
> *To:* Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.
> IMPROVEDIAGNOSIS.ORG>; Bob Latino <blatino at reliability.com>
> *Subject:* RE: [IMPROVEDX] Definition of Diagnosis Error
>
>
>
> Dear Bob,
>
> I think that is the wrong way to think about it. Going forward, the
> IOM/NAM definition should be thought of as *THE* definition of diagnostic
> error.
>
> There will be different ways to operationalize that definition, and there
> will remain some differences of opinion over how best to do that.
>
> However, we cannot keep re-litigating the definition ad infinitum. There
> is no “right” answer or true consensus, so the IOM/NAM has settled the
> matter for us.
>
> David
>
>
>
>
>
>
>
> *David E. Newman-Toker, MD PhD*
> Professor of Neurology, Ophthalmology, & Otolaryngology
>
>
>
> *Director, Division of Neuro-Visual & Vestibular Disorders*
>
>
> *http://www.hopkinsmedicine.org/neurology_neurosurgery/centers_clinics/vestibular/team/*
> <http://www.hopkinsmedicine.org/neurology_neurosurgery/centers_clinics/vestibular/team/>
>
>
>
> *Director, Armstrong Institute Center for Diagnostic Excellence*
>
>
> *http://www.hopkinsmedicine.org/armstrong_institute/center_for_diagnostic_excellence/*
> <http://www.hopkinsmedicine.org/armstrong_institute/center_for_diagnostic_excellence/>
>
>
>
> Johns Hopkins University School of Medicine
> Johns Hopkins Hospital; CRB-II, Room 2M-03 North
>
> 1550 Orleans Street; Baltimore, MD 21231
>
> Email: toker at jhu.edu
>
>
>
> Administrator: Doug Montague (410) 955-2536; dmontag6 at jhu.edu
>
>
> Confidentiality Notice: The information contained in this email is
> intended for the confidential use of the above named recipient. If the
> reader of this message is not the intended recipient or person responsible
> for delivering it to the intended recipient, you are hereby notified that
> you have received this communication in error, and that any review,
> dissemination, distribution, or copying of this communication is strictly
> prohibited. If you have received this in error, please notify the sender
> immediately by telephone at the number set forth above and destroy this
> email message. Thank you.
>
>
>
>
>
> *From:* Bob Latino [mailto:blatino at RELIABILITY.COM
> <blatino at RELIABILITY.COM>]
> *Sent:* Thursday, January 19, 2017 6:17 AM
> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> *Subject:* Re: [IMPROVEDX] Definition of Diagnosis Error
>
>
>
> So, based on all of this feedback, it is safe to state that there is no
> singular, universally accepted definition for Diagnosis Error?
>
>
>
> *Robert J. Latino, CEO*
>
> Reliability Center, Inc.
>
> 1.800.457.0645 <(800)%20457-0645>
>
> blatino at reliability.com
>
> www.reliability.com
>
> [image: linkedin logo signature file]
> <https://www.linkedin.com/company/958495?trk=tyah&trkInfo=clickedVertical%3Acompany%2CclickedEntityId%3A958495%2Cidx%3A1-1-1%2CtarId%3A1464096807851%2Ctas%3Areliability%20center%2C%20inc.>
>
>
>
> *From:* Tom Benzoni [mailto:benzonit at GMAIL.COM <benzonit at GMAIL.COM>]
> *Sent:* Wednesday, January 18, 2017 2:18 PM
> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> *Subject:* Re: [IMPROVEDX] Definition of Diagnosis Error
>
>
>
> The major class missing is the largest.
>
> "Irrelevant"
>
> Tom
>
>
>
> On Jan 18, 2017 12:54, "Mark Graber" <mark.graber at improvediagnosis.org>
> wrote:
>
>
>
>
>
>
> I've used the missed - wrong - delayed categories, which were originally
> created by the Australian Patient Safety Foundation decades ago.  These
> categories are useful in clarifying what things we're talking about in
> regard to diagnostic error.  The classification isn't perfect, because
> there will be overlap in the cases where a diagnosis is initially
> mis-labeled, but then correctly diagnosed later on (so originally wrong,
> but ultimately delayed).  Other limitations include the need to have some
> near-gold-standard way of knowing the correct diagnosis, and the fact that
> the categorization can only be done reliably in retrospect.
>
>
>
> None of the other definitions are perfect either, but they are all useful,
> and highly complementary, depending on your goals.  For performance
> improvement research, the definitions that focus more on the DIAGNOSTIC
> PROCESS are especially useful:  Gordy Schiff's definition centers on
> identifying breakdowns in the process, and Hardeep Singh's definition
> centers on finding 'missed opportunities'.
>
>
>
> The IOM definition is the only patient-focused definition; it starts off
> as another 'label' failure, but then includes that key process step of
> communicating the diagnosis to the patient.
>
>
>
> A paper by David Newman-Toker is attached that provides more detail for
> anyone interested, and also attached are the attributions for these 4
> definitions.
>
>
>
>    Mark
>
>
>
> Mark L Graber, MD FACP
>
> President, Society to Improve Diagnosis in Medicine
>
> Senior Fellow, RTI International
>
> Professor Emeritus, Stony Brook University
>
>
>
>
>
> On Jan 18, 2017, at 8:17 AM, Tom Benzoni <benzonit at GMAIL.COM> wrote:
>
>
>
> There are too many flaws in the definition to give it credibility.
>
>
>
> Tom
>
>
>
> On Jan 18, 2017 8:33 AM, "Bob Latino" <blatino at reliability.com> wrote:
>
> Is this IOM Definition of Diagnosis Error an accepted definition by SIDM?
>
>
> What is Diagnostic Error?
>
> The Institute of Medicine recently defined diagnostic error as the failure
> to (a) establish an accurate and timely explanation of the patient’s health
> problem(s) or (b) communicate that explanation to the patient. Simply put,
> these are diagnoses that are missed altogether, wrong, or should have been
> made much earlier.
>
> These categories overlap, but examples help illustrate some differences:
>
> *A missed diagnosis *refers to a patient whose medical complaints are
> never explained. Many patients with chronic fatigue, or chronic pain fall
> into this category, as well as patients with more specific complaints that
> are never accurately diagnosed.
>
> *A wrong diagnosis* occurs, for example, if a patient truly having a
> heart attack is told their pain is from acid indigestion. The original
> diagnosis is found to be incorrect because the true cause is discovered
> later.
>
> *A delayed diagnosis* refers to a case where the diagnosis should have
> been made earlier. Delayed diagnosis of cancer is by far the leading entity
> in this category. A major problem in this regard is that there are very few
> good guidelines on making a timely diagnosis, and many illnesses aren’t
> suspected until symptoms persist, or worsen.
>
>
>
>
>
> *Robert J. Latino, CEO*
>
> Reliability Center, Inc.
>
> 1.800.457.0645 <(800)%20457-0645>
>
> blatino at reliability.com
>
> www.reliability.com
>
> <image001.jpg>
> <https://www.linkedin.com/company/958495?trk=tyah&trkInfo=clickedVertical%3Acompany%2CclickedEntityId%3A958495%2Cidx%3A1-1-1%2CtarId%3A1464096807851%2Ctas%3Areliability%20center%2C%20inc.>
>
>
> ------------------------------
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>
> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
> Medicine
>
> To learn more about SIDM visit:
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>
>
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>
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>
>
> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
> Medicine
>
> To learn more about SIDM visit:
> http://www.improvediagnosis.org/
>
>
>
>
>
>
>
>
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>
> To learn more about SIDM visit:
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>
>
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> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
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>
> To learn more about SIDM visit:
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>
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>
> To learn more about SIDM visit:
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>
>
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>
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Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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