Definition of Diagnosis Error

Bruno, Michael mbruno at PENNSTATEHEALTH.PSU.EDU
Fri Jan 20 13:41:22 UTC 2017


I'm quite sure this is true for every step in the diagnostic pathway.  The vast majority of radiologist errors are never discovered.

[cid:image004.png at 01D112FF.F77F98B0]
Michael A. Bruno, M.S., M.D., F.A.C.R.
Professor of Radiology & Medicine
Vice Chair for Quality & Patient Safety
Chief, Division of Emergency Radiology
Penn State Milton S. Hershey Medical Center
* (717) 531-8703  |  * mbruno at hmc.psu.edu<mailto:mbruno at hmc.psu.edu>  |  6 (717) 531-5737
[https://infonet.pennstatehershey.net/documents/396359/10678301/Medical+Center+Two+Color/4ea2250e-2e29-4b9f-8d2e-2911ed1af1ea?t=1456671057665]


From: Koppel, Ross J [mailto: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<mailto:Rkoppel at sas.penn.edu>
Also, Prof of Biomedical Informatics
 SUNY Buffalo


-------- Original message --------
From: "Ely, John" <john-ely at UIOWA.EDU<mailto:john-ely at UIOWA.EDU>>
Date: 1/19/17 1:44 PM (GMT-05:00)
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto: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<mailto: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/

Director, 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<mailto:toker at jhu.edu>

Administrator: Doug Montague (410) 955-2536; dmontag6 at jhu.edu<mailto: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]
Sent: Thursday, January 19, 2017 9:27 AM
To: David Newman-Toker <toker at jhu.edu<mailto:toker at jhu.edu>>; Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto: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
blatino at reliability.com<mailto:blatino at reliability.com>
www.reliability.com<http://www.reliability.com>
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From: David Newman-Toker [mailto:toker at jhu.edu]
Sent: Thursday, January 19, 2017 9:07 AM
To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>; Bob Latino <blatino at reliability.com<mailto: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/

Director, 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<mailto:toker at jhu.edu>

Administrator: Doug Montague (410) 955-2536; dmontag6 at jhu.edu<mailto: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]
Sent: Thursday, January 19, 2017 6:17 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto: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
blatino at reliability.com<mailto:blatino at reliability.com>
www.reliability.com<http://www.reliability.com>
[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]
Sent: Wednesday, January 18, 2017 2:18 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto: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<mailto: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<mailto: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<mailto: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<tel:(800)%20457-0645>
blatino at reliability.com<mailto:blatino at reliability.com>
www.reliability.com<http://www.reliability.com/>
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Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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