Definition of Diagnosis Error

Tom Benzoni benzonit at GMAIL.COM
Fri Jan 20 20:42:29 UTC 2017


Mr. Latino
I think, by observation, we may be making little progress because we still
aren't following Deming's advice to ask the people doing the work.
Tom

On Jan 20, 2017 12:01 PM, "Bob Latino" <blatino at reliability.com> wrote:

THANK YOU, Mark!!!



You have clearly articulated my point, way better than I am capable of ever
doing.



You have been looking at this since 1975.



So after 42 years we are still at the point of not clearly defining
diagnosis, diagnosis error or an acceptable taxonomy, to help break the
problem down into its manageable components...and actually implement
effective countermeasures.  During this time frame I am sure the U.S. has
spent billions on compensating for this problem as well as trying to solve
this problem.  Many brilliant, well-educated, esteemed professionals from
across the healthcare spectrum have been tasked to solve this problem.



Why has there been so little progress?





*Robert J. Latino, CEO*

Reliability Center, Inc.

1.800.457.0645 <(800)%20457-0645>

blatino at reliability.com

www.reliability.com

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*From:* Mark Gusack [mailto:gusackm at comcast.net]
*Sent:* Thursday, January 19, 2017 10:48 PM
*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



Mr. Latino, the answer is no.



Perhaps we should step back just a bit before trying to have this
conversation.  Before we can discuss what a diagnostic error is, we need to
ask the following:



Æ  What is a diagnosis?  Are we looking for a label for a set of clinical
and laboratory findings, or an underlying cause the leads to them, or a
therapy that successfully treats the clinical condition we identify?

Æ  What about screening for risks that may lead to a future diagnosis?  Is
that a diagnosis also?  Such as ‘prediabetes’ and ‘precancerous lesions’.

Æ  What is the difference between a diagnosis and the diagnostic process
that leads, hopefully, to a correct diagnosis? Are we looking for empirical
or mechanistic approaches to diagnosis?  Do we use a shotgun approach or
branch logic both of which exhibit advantages and risks?  What do we do
with probabilistic issues that plaque the diagnostic process regardless of
which approach we use?



Then, we might be able to develop a taxonomy of mutually agreed upon
terminology that allows us to define the phrase ‘diagnostic error’.  And if
we are successful in that endeavor we can move to the next step by asking
the following questions:



Æ  Are we talking about all errors or just those that lead to an unexpected
outcome?

Æ  Are we talking about all unexpected outcomes or just those that lead to
some degree of failure?

Æ  Are we talking about all failures or just those that lead to patient
harm?

Æ  Are we talking about all harm or what is *Acceptable Harm?  After all,
it will be impossible to eliminate all harm.*

Æ  Perhaps we could rephrase that as: What is *Acceptable Risk* of
inflicting some degree of harm on our patients during the diagnostic
process and in the rendering of a diagnosis?



Additional questions that arise as we explore this matter are:



Æ  Can we ever know about all possible diagnoses that exist?  Look at how
many new ones have been discovered over the last fifty years.  With
genetics we will find many more.  And so a correct diagnosis today may be
incorrect tomorrow.

Æ  Can we define a process or processes that assures a high probability
that a correct diagnosis will be rendered where one exists and we know
about it?

Æ  What can we do to assure we maximize the probability that a correct
diagnosis is rendered within the limitations imposed by the scope of our
knowledge as well as the impact of economic, societal, and cognitive
factors?



I’ve been dealing with these issues since 1975 when I was a Clinical
Engineer at the GWU Medical School working under Dr. William S. Yamamoto.
He was asking many of these questions way back then…



Mark Gusack, M.D.



*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

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<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
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To learn more about SIDM visit:
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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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Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
Medicine

To learn more about SIDM visit:
http://www.improvediagnosis.org/

------------------------------


To unsubscribe from IMPROVEDX: click the following link:
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or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG

Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
Medicine

To learn more about SIDM visit:
http://www.improvediagnosis.org/






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


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