Definition of Diagnosis Error

Garry Nieuwkamp Garry.Nieuwkamp at HEALTH.NSW.GOV.AU
Fri Mar 3 00:41:37 UTC 2017


One of my favourite passages in the Nicomachean Ethics is where Aristotle says that it is the mark of an educated man not to attach greater precision to a subject than the subject matter will allow. We may want to carve nature at its joints but perhaps it wont be carved. I keep this warning in view when I read about diagnostic error.

________________________________
From: Vic Nicholls [nichollsvi2 at GMAIL.COM]
Sent: Wednesday, 1 February 2017 5:30 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] Definition of Diagnosis Error


Might I add that if you are blessed with a medical library in your area, see if some of your patients would be willing to use the medical databases. Ours allows public access to databases like UpToDate at the computers there for free.

Patients can help busy doctors out when they bring this sort of information to their attention. That helps more than "Dr. Google".

Vic

On 1/31/2017 11:51 AM, HM Epstein wrote:
I agree wholeheartedly with Peggy! If I had looked earlier at my son's blood tests that the pediatrician had misread, year after year, he might not have suffered for seven years before being properly diagnosed and treated. This is my first piece of advice to every new parent, and patient whose health is not improving: Routinely ask for your test results and patient records at every visit. If the patient portal displays this information, great. But often the patient portal is not thorough and patients/caregivers need to request the missing data.

Best,
Helene

Sent from my iPhone



On Jan 20, 2017, at 6:21 AM, Bob Latino <blatino at RELIABILITY.COM<mailto: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
blatino at reliability.com<mailto:blatino at reliability.com>
www.reliability.com<http://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<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>; Bob Latino <blatino at reliability.com<mailto: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]
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>
<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: 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:%28800%29%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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