[No SPF Record] Re: [IMPROVEDX] Transfers/referrals

Rory Jaffe rjaffe at CHPSO.ORG
Thu Jan 11 00:14:28 UTC 2018


Sorry, I worded that a bit inartfully. I agree with you that misdiagnosing a viral URI is a big issue, but I was trying to say that it shouldn’t be approached with the same “cognitive processes” lens we tend to use for, e.g., dissecting aortic aneurysm, and it muddies the water to include the URI diagnosis issue in an analysis of diagnostic error.

To me, the URI diagnosis issue, while technically a diagnostic error, is primarily a function (as you note) of our socio-technical system—reimbursement, patient expectations, a bias towards overtreatment out of fear of malpractice liability, etc…

So I’d approach the URI diagnosis error primarily through population-based mechanisms (e.g., population education campaigns, changes in reimbursement, changes in malpractice law) rather than cognitive process improvement, though there are indeed some cognitive biases at work here as well (e.g., under-weighting of long-term rare but serious risks such as achilles tendon rupture) and there would be some limited benefit to addressing those cognitive biases.

From: Tom Benzoni [mailto:benzonit at gmail.com]
Sent: Tuesday, January 09, 2018 6:55 AM
To: Society to Improve Diagnosis in Medicine <IMPROVEDX at list.improvediagnosis.org>; Rory Jaffe <rjaffe at chpso.org>
Subject: Re: [IMPROVEDX] [No SPF Record] Re: [IMPROVEDX] Transfers/referrals

I think misdiagnosis must be treated as misdiagnosis without placing "value judgment."
Placing a patient on an antibacterial agent when they are experiencing a viral event not only cannot help the patient, it can hurt the community. It allocates $ to the drug company and the health care system; I get paid more when I write a script than when I recommend OTC. (If I write ibuprofen 600 mg, an Rx, I get a bonus that I don't get if I recommend (3) 200 mg Advil. Sorry, I didn't make this system.) Additionally and more worrying to me, if an antibacterial is written for a viral event, the patient is open to damage from several angles: we are seeing more C diff infections, tendonopathy (e.g., ruptured Achilles tendon) is occurring in patients who cannot benefit from the Rx, and we're inducing "medication-seeking behavior" in patients who have a self-limited disease. And we haven't even gotten to "post-antibiotic era" scenarios.
So I would strongly advocate for placing antibacterial Rx for viral illness as both a diagnostic and therapeutic error.
I understand this will make the % of misdiagnoses skyrocket, but ignoring it will not make this error disappear.
tom

On Mon, Jan 8, 2018 at 6:03 PM, Rory Jaffe <rjaffe at chpso.org<mailto:rjaffe at chpso.org>> wrote:
And even then, methods of getting counts of diagnostic errors are very insensitive, unless your definition is very limited.

You can get pieces of the answer with some reasonable accuracy—e.g., pathology mis-reads, diagnostic errors resulting in malpractice suits. But getting the big picture? No, don’t think we have any idea. For example, see Graber, M. L. (2013). The incidence of diagnostic error in medicine. BMJ Quality & Safety, 22 Suppl 2(Suppl 2), ii21-ii27. http://doi.org/10.1136/bmjqs-2012-001615.

Clinicians in general do a poor job of documenting their cognitive work, so unless we actively solicit this information from physicians and their patients we’re not going to get anywhere close to an answer.

And then there’s the issue of what diagnostic errors do we care about counting? Misdiagnosing a viral URI as a bacterial infection is more a population health issue than an individual patient safety issue, but each time that happens we’re dealing with a diagnostic error. The implications of this type of error and the types of interventions needed are much different from, say, missed diagnoses of dissecting aneurysms in the ED.

With such a heterogeneous problem as diagnostic error, I’m not sure that counting and lumping all errors together to say, for example, “1/3 of all errors are diagnostic” is of any use.

From: Harry Burke [mailto:harry.burke at gmail.com<mailto:harry.burke at gmail.com>]
Sent: Monday, January 08, 2018 3:02 PM
To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>; Rory Jaffe <rjaffe at chpso.org<mailto:rjaffe at chpso.org>>
Subject: Re: [IMPROVEDX] [No SPF Record] Re: [IMPROVEDX] Transfers/referrals

The incidence depends on how you define diagnostic errors and how you detect diagnostic errors.
Sent from my iPhone

On Jan 8, 2018, at 5:43 PM, Rory Jaffe <rjaffe at CHPSO.ORG<mailto:rjaffe at CHPSO.ORG>> wrote:
There are no reliable estimates of the incidence of diagnostic errors.

Rory

From: robert bell [mailto:0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG]
Sent: Sunday, January 07, 2018 10:58 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: [No SPF Record] Re: [IMPROVEDX] Transfers/referrals

Dear all,

It is said that of the errors in medicine two thirds are standard errors while one third are diagnostic (does anyone know where those figures came from?).

It this is true then the next question would seem to be what is the impact of standard errors (from computers, hand offs, medication, laboratory and radiology errors, etc., etc.) on diagnostic errors. Is it a  small of large figure? Are there  any estimates?

Then the question arises should we as a community/organization be dealing in someway with all errors and not solely diagnostic.

In fact, if the standard errors significantly effect diagnoses, will we be able to easily prove that any diagnostic approach is worthwhile?

Will historical analyses work? How would you compensate for standard error rates being different in different hospitals and HC facilities.

Do we need to know the level of effect of standard errors on diagnostic errors in different facilities?

Robert Bell, M.D.


________________________________

Address messages to: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>

To unsubscribe from IMPROVEDX: click the following link:
http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1
or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG>

Visit the searchable archives or adjust your subscription at: http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX

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

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

________________________________

Address messages to: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>

To unsubscribe from IMPROVEDX: click the following link:
http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1 or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG>

Visit the searchable archives or adjust your subscription at: http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX
Moderator:David Meyers, Board Member, Society for Improving Diagnosis in Medicine

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


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

Address messages to: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG

For additional information and subscription commands, visit:
http://www.lsoft.com/resources/faq.asp#4A

http://LIST.IMPROVEDIAGNOSIS.ORG/ (with your password)

Visit the searchable archives or adjust your subscription at:
http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX

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

To unsubscribe from the IMPROVEDX list, click the following link:<br>
<a href="http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1" target="_blank">http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1</a>
</p>

HTML Version:
URL: <../attachments/20180111/2859f810/attachment.html>


More information about the Test mailing list