Definition of Diagnosis Error

Kohn, Michael Michael.Kohn at UCSF.EDU
Sun Feb 5 22:24:22 UTC 2017


We could be wrong about the effectiveness of certain treatments for certain conditions.  In focusing on either failing to give effective treatment or giving unnecessary treatment, I am assuming that we know whether and when a treatment is effective, and that we can roughly estimate the magnitude of the benefit when given appropriately and the harm when given inappropriately.  I should broaden my definition of treatment to include any decision that is helpful when the patient has a particular condition and harmful when he doesn't.  Focusing on errors in decision-making does not conform with the other definitions of diagnostic error, because the true meaning of diagnosis is simply assigning the right name to a patient's illness.   You may think it is always necessary to know the right name of an illness before you can recommend a treatment to the patient, but I disagree.  We used to get kidney biopsies on children with nephrotic syndrome in order to separate focal sclerosing glomerulonephritis from minimal change disease, but now we skip the biopsy and treat with steroids.  If the child gets better, we never know which it was, but we also saved the child a kidney biopsy.  The error here would be failure to treat with steroids, and yes, I am assuming that steroids are generally effective.

Best,

Michael





Michael A. Kohn, MD, MPP

Associate Professor

Epidemiology and Biostatistics

(Email created using voice recognition.  Please excuse transcription errors.)

________________________________
From: Tom Benzoni [benzonit at gmail.com]
Sent: Sunday, February 05, 2017 1:17 PM
To: Society to Improve Diagnosis in Medicine; Kohn, Michael
Subject: Re: [IMPROVEDX] Definition of Diagnosis Error

To add a 3rd dimension and using the issues discussed, believing in a treatment doesn't make it work.
TPA is a case in point; we'd like to have a treatment for stroke symptoms so we apply old cardiac logic.
(I remember streptokinase, too.)
Note how mechanical thrombectomy appears to be better than TPA.
Thus, if you apply a treatment that doesn't work but is currently believed to work (and we have myriad examples of these,) is that an error?
Is it an error to follow guidelines that are accepted but are wrong?
(Remember giving 30 mg/kg methylpred for spinal injuries? CDC and other august bodies promulgated guidelines extolling this.)
tom

On Sun, Feb 5, 2017 at 12:29 PM, Kohn, Michael <Michael.Kohn at ucsf.edu<mailto:Michael.Kohn at ucsf.edu>> wrote:
Dear Colleagues,

As per my prior post, I see two types of diagnostic error: 1) failing to provide effective treatment for something the patient has, and 2) treating unnecessarily for something the patient doesn't have.  If you believe tPA is effective treatment for acute stroke, then failing to provide it to a patient with a stroke is the first type of error, and providing it to a patient with a stroke mimic, such as a complicated migraine, is the second type of error.  Overdiagnosis is the second type of error.  Giving the wrong treatment combines (1) failing to treat with (2) treating unnecessarily.

One correspondent correctly pointed out that these are actually treatment errors.  I am focused on incorrect decisions, not incorrect naming of a patient's illness.  With my narrower view, failing to apply the correct name to a benign, self-limited condition is not an error so long as you don't provide unnecessary and harmful treatment.  Also, failing to distinguish between two illnesses with the same effective treatment is not an error unless you fail to provide that treatment.  I am not one of those physicians who tries to please patients by applying a Greek name to their benign problem (cephalgia for headache), but this isn't necessarily an error.  Failing to identify an aneurysmal subarachnoid hemorrhage is an error because prompt referral for coiling can save the patient's life.

One other point: all of this refers to patients who have symptoms, i.e., they feel sick.  Screening of patients with no known symptoms of disease is a different matter.  That is primarily though not exclusively what H. Gilbert Welch was referring to in "Overdiagnosed: Making People Sick in the Pursuit of Health".

Respectfully,

Michael

Michael A. Kohn, MD, MPP


Chairman, Emergency Department

Mills-Peninsula Medical Center


Associate Professor

UCSF Epidemiology and Biostatistics

(Email created using voice recognition.  Please excuse transcription errors.)

________________________________
From: Joe Graedon [jgraedon at GMAIL.COM<mailto:jgraedon at GMAIL.COM>]
Sent: Sunday, February 05, 2017 5:32 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] Definition of Diagnosis Error

Bob,

I think the IOM definition is comprehensive and helpful.

Joe

Sent from my iPad

On Jan 18, 2017, at 8:54 AM, Bob Latino <blatino at RELIABILITY.COM<mailto:blatino at RELIABILITY.COM>> wrote:

Is over-diagnosis considered a diagnostic error?

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>
<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.>

From: Bob Latino [mailto:blatino at RELIABILITY.COM]
Sent: Wednesday, January 18, 2017 6:23 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: [IMPROVEDX] Definition of Diagnosis Error

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>
<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 to Improve Diagnosis in Medicine


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