TR: [IMPROVEDX] Definition of Diagnosis Error

Grubenhoff, Joe Joe.Grubenhoff at CHILDRENSCOLORADO.ORG
Fri Jan 20 17:48:29 UTC 2017


Bob, this is an excellent analogy.

We have a robust data set regarding missed appendicitis and negative appendectomies that was collected to address problems around overuse of CT compared to similar children’s hospitals. We are developing an investigation to look at the differences in the “diagnostic journeys” between missed/delayed dx, timely diagnosis (that is accurate = positive appendectomy) and erroneous dx (negative appy). Of course we can’t ask each of our 170 providers in our ED/UC network about their thinking in each of the over 600 cases we have collected so makes it more difficult to find the “human factor” decision that seemed right at the time. However, considering a concept I learned about at the last DEM conference from Michael Kanter, we will be looking at test ordering and treatment that may indicate a reasoning problem. A child presenting with abdominal pain (which is often something benign like constipation) may be at risk of his provider’s posterior probability error and that provider orders a KUB to “prove” the child is FOS (even though 2 pediatric societies tell us not to do this). This is compounded by search satisficing or confirmation bias and the KUB is interpreted (accurately or not) as showing a large stool burden (even though most of our peds radiologists decline to comment beyond the extremes). The child is placed on polyethylene glycol and sent home. Maybe he has 1-2 more visits before someone catches on to the fact this isn’t constipation and performs an appy work-up. So as a proxy to talking to each provider can we use things like (KUB, laxative Rx, # of visits, a rapid strep for fever and belly pain) to identify where our reasoning went sour? We work the problem backward, find a potential reasoning flaw, understand the scale of the problem then work it forward to find out (riffing off work of folks like Hardeep Singh) to think about how we can create a trigger for a provider to move from sys 1 to sys 2 thinking.

Hell, it may not work but certainly just like in the engineering example we’re bound to learn something even if it’s not the “something” we were expecting. We’re using appy as a model since we have the dataset. But the real question for me as an ER doc is: “Which 1 or 2 of the 30 kids seen in my ED today for abdominal pain has an emergent condition (appy, new tumor, auto-immune hepatitis, etc)?” And, how do I avoid my own heuristic biases without becoming incredibly inefficient or overtesting everyone?

Oi!

jg

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Joe Grubenhoff, MD, MSCS| Associate Professor of Pediatrics
Section of Emergency Medicine | University of Colorado
Associate Medical Director - Clinical Effectiveness
Children's Hospital Colorado
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From: Bob Latino [mailto:blatino at RELIABILITY.COM]
Sent: Friday, January 20, 2017 4:48 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] TR: [IMPROVEDX] Definition of Diagnosis Error

Exactly Marius, my entire point is about taking action now so the patients benefit today...not allowing 'paralysis by analysis' to stifle measurable progress.

Engineers investigate failures by starting with the undesirable outcome (injury, equipment failure, process failure, delays, whatever).  They collect evidence from the failure scene as well as other data related to the event (i.e. - failure histories, training records, OEM specs/procedures, etc). They reenact the failure by drilling backwards in time, and understanding the cause-and-effect relationships that led up to the bad outcome.  They are acutely aware that eventually, during that journey backwards in time, they will come across a human contributor.  This human contributor will be a person or group that made an inappropriate decision at the time, resulting in an error of omission or commission.  Engineers don't care who made the poor decision, because they realize it is more important to understand why that well-intentioned individual thought the decision they made, was the appropriate one at the time.  That understanding of human reasoning is the most critical step of an investigation and will uncover system deficiencies that often feed decision-makers insufficient or inadequate data.

Is a diagnosis error any different?  Aren't we first interested in the bad outcome that occurred as a result (that is often how we know there was a problem at all)?  Can't/don't we want to drive that backwards and find the human contribution? IF a decision error was made regarding diagnosis, don't we want to understand the reasoning of why the person rendering the improper diagnosis, felt it was correct?

If we looked at diagnosis error from a clinical problem solving perspective, how would you approach it?  Would you have to gather data to understand the symptoms?  Would you have to understand what was causing the symptoms to surface? Would you validate all of this via available testing protocols (evidence qualification, verification & validation [QV&V])?

It just seems like we all agree diagnosis error is a huge problem that adversely affects a significant amount of patients every day, yet there seems to be little progress on the front lines that will give the patient's relief and provide more safety NOW.  There is an immense amount of talk, but little action on the front lines.

Why?

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: Marius Laurent [mailto:marius.laurent at SKYNET.BE]
Sent: Thursday, January 19, 2017 1:59 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: [IMPROVEDX] TR: [IMPROVEDX] Definition of Diagnosis Error

The problem of definition is a frequent question in medicine and the answer is not trivial. When working on diagnosis like Ventilator Associated Pneumonia (VAP), you’ll find a lot of definitions with different criteria, and different incidences of course. If you need a protected brush specimen in your definition of VAP, as it is the case in France, your incidence of VAP will be lower than in the rest of the world, but the problem of VAP remain the same, and groups of intensivists seeks actively to prevent it (see the work of Pronovost). And succeed. What I mean is that sometimes action may precede theory, and that action is more important than definition. We know that Dx errors exists even if the definition remains elusive, and we begin to imagine how to act. Even if we have no real outcome indicator. I wonder if one day we’ll have one? Waiting for perfection before action may be deleterious I think.

Marius Laurent
Federal Health Service, Belgium

De : David Newman-Toker [mailto:toker at JHU.EDU]
Envoyé : jeudi 19 janvier 2017 15:37
À : IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Objet : 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>

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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>
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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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