Definition of Diagnosis Error

HM Epstein hmepstein at GMAIL.COM
Tue Jan 31 16:44:22 UTC 2017


May I add one to your list, Peter, based on personal experience and dozens of patient stories I've collected to date? 

No diagnosis: when the physician tells the patient that they are healthy when they're not, or that the tests are all negative but chooses not to continue to search for an underlying cause of symptoms, or throws up his hands and tells the patient, "It's all in your head." 

This diagnostic error is most often found amongst patients with long diagnostic journeys. 

Best,
Helene 

Sent from my iPhone



On Jan 19, 2017, at 11:22 PM, Elias Peter <pheski69 at GMAIL.COM> wrote:

I think these are treatment errors, not diagnostic errors.  Diagnosis and treatment are linked but not identical, in that a diagnosis (whether correct or not) can be followed by no treatment, or by some combination of correct/incorrect treatment. 

I have always thought of diagnostic accuracy using the following schema:

Correct diagnosis: making the diagnosis of something that is present and is causing the signs or symptoms being evaluated.
Incomplete diagnosis: making the diagnosis of something that is present, but missing other pertinent diagnoses.
Irrelevant diagnosis: making the diagnosis of something that is present, but is not related to the signs or symptoms being evaluated. This includes things often called incidentalomas or red herrings.
Incorrect diagnosis: diagnosing something that is not present. Over diagnosis, for example diagnosing a breast cancer that would never have caused clinical illness based on an abnormal mammogram, is one form of incorrect diagnosis. Another form is mislabeling: diagnosing a condition that is not present, such as diagnosing viral pleurisy in a patient with pulmonary embolus. 

I do not consider these to be mutually exclusive. 

Peter E;ias, MD

> On 2017.01.19, at 4:10 PM, Kohn, Michael <Michael.Kohn at UCSF.EDU> wrote:
> 
> Dear colleagues,
> 
> There are two general categories of diagnostic error:1) failing to treat the patient for something he or she has, and 2) treating for something he or she doesn't have.  
> 
> For the emergency physician, discharging a chest-pain patient who turns out to have a myocardial infarction is a diagnostic error, but so is admitting a chest-pain patient who turns out to have esophageal reflux, even if we are willing to make 10 of the second type of error (unnecessary hospitalization) in order to avoid one of the first type of error (“missing” an MI).  
> 
> Of course, we can make both types of error simultaneously -- treating the chest-pain patient with thrombolytics for MI when he turns out to have aortic dissection.
> 
> Best,
> 
> Michael
> 
> Michael A. Kohn, MD, MPP
> Associate Professor
> Epidemiology and Biostatistics 
> (Email created using voice recognition.  Please excuse transcription errors.)
> From: Bob Latino [blatino at RELIABILITY.COM]
> Sent: Thursday, January 19, 2017 2:07 PM
> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> Subject: Re: [IMPROVEDX] Definition of Diagnosis Error
> 
> 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/
>  
> 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
>  
> 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] 
> 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
> blatino at reliability.com
> www.reliability.com
> <image002.jpg>
>  
> 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>; 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/
>  
> 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
>  
> 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] 
> 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
> blatino at reliability.com
> www.reliability.com
> <image004.jpg>
>  
> From: Tom Benzoni [mailto: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
> blatino at reliability.com
> www.reliability.com
> <image001.jpg>
>  
> 
> 
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Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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