Case Closed: Wendy L. Longmire, JD Diagnostic Error Ortale, - - PowerPoint PPT Presentation

Case Closed: Diagnostic Error

Wendy L. Longmire, JD Ortale, Kelley, Herbert & Crawford

What we will cover

• Diagnostic Error Data
• Cognitive Factors
• Systems Issues
• Lessons Learned from

Case Studies

• Appropriate

Supervision

• Improvement

Strategies

Agenda

Why a course on Diagnostic Error?

• Diagnostic error is the patient’s

#1 concern when surveyed

The toll of Dx Error, Leape et al. JAMA 288:2405, 2002 Singh et al. BMJ Qual Safety 21: 93-100, 2012

• 40,000 – 80,000 deaths/year
• 1 in 20 primary care patients involved

diagnostic error every year

• More than half happen in Ambulatory care

National Data (PIAA)

Internal Medicine, General and Family Practice

• Most prevalent and expensive misadventure:

Diagnostic Error

• Most expensive condition:

Chest pain

• Most prevalent misdiagnosed condition:

Malignant neoplasms of the bronchus and lung

Physician Insurers Association of America-PIAA

• Cancer
• Infections
• Pulmonary embolism
• Acute coronary syndrome
• Fractures
• Cerebrovascular disease
• Appendicitis

Pennsylvania Patient Safety Authority 2010

Top Misdiagnosed Conditions

Common Failures in Diagnosis

• Inadequate H & P
• Failure to follow a

cancer screening protocol

• Failure to include

cancer in differential dx

• Failure to order appropriate tests or referral
• Incorrect interpretation of tests
• Failure to track tests and notify patients
• Inadequate discharge planning or follow-up

Challenges to Reliable Diagnosis

• Atypical presentation or unusual course
• Cognitive – recognizing acuity/severity
• Patient factors
• Noncompliant with treatment, failure to

follow-up

• Poor historians or language barriers
• Systems issues
• Access to testing
• Delays or misinterpretations
• Fragmented care

Heuristics: A Double-Edged Sword

• Mental shortcuts commonly used in decision-making

and frequently correct. But, can lead to faulty reasoning.

• “Familiarity breeds conclusions”
• Occam’s razor is an example of a medical heuristic; it

dictates that the simplest explanation for all presenting symptoms should be sought

• Common things are common
• If you hear hoofbeats, think of horses instead of

zebras

Elstein AS, Schwartz A. Clinical problem solving and diagnostic decision making: selective review

• f the cognitive literature. BMJ 2002; 324:729–732.

Cognitive Bias

• Anchoring – tendency to stay with an original

diagnosis or make a “snap judgment”

• Availability- immediately comes to mind
• Premature closure- failure to consider

possibilities once initial diagnosis is reached

• Confirmation bias- assigning preference to

findings that confirm diagnosis or strategy

• Context errors- clinician biased by patient

history, previous diagnosis, etc. leading to the wrong context for diagnosis

“How Doctors Think”

• Dr. Groupman focuses on how the doctor-patient

interaction influences diagnosis and espouses:

• Practice conscious, reflective review
• Patients should actively participate in care
• Shore up knowledge gaps

Suggested asking two questions before diagnosing:

1. “What else might this be?” 2. “Could there be two things going on here?”

How Doctors Think, Jerome Groupman, MD

What Happened Here?

• Heuristics/Cognitive issues
• Adequate H & P?
• Differential diagnosis?
• Communication/Systems failures
• Hand off failure
• Problems with documentation
• Subjective, derogatory comments

Complex Care Is a Team Effort

Strive for:

• Effective Communication
• Consistent Office Processes and

Systems

• Good Medical Record Documentation

Poor Communications = Errors 70% of sentinel events reported to Joint Commission

caused by poor communication

• 44% breakdown in communication with patients or

among colleagues (handoffs)

• 21% misinformation in the medical record
• 18% mishandling of patient requests or messages
• 12% inaccessibility of medical records
• 5% inadequacy of reminder systems

Source: Woolf SH, Kuzel AJ, Dovey SM, et al. A string of mistakes: the importance of cascade analysis in describing, counting, and preventing medical errors. Ann Fam Med 2004 Jul-Aug;2(4):317-26.

Continuity of Care

• You don’t need to find and fix everything
• Average patient has 3.6 providers
• Refer to specialists and communicate the

relationship to patients

• ER doctor: “It’s important you see Dr. Reed for

this belly pain.”

• Ask patient to update you on other care

providers and treatment plans

• “What did the ER doctor tell you this could be?”

Handling Telephone Calls

• Do you have written

policies?

• Do you carefully prioritize

phone calls for the

physician to ensure urgent

• nes are addressed

immediately?

• Do you track 2nd or 3rd call for same problem?
• Do you document after-hours calls?

Documenting After-Hours Calls

• Calls about positive test

results reported to patients

• What was action taken/patient advised?
• Medical advice given or history
• btained
• To consultants about a specific

patient

• Medication prescribed or

changed

SVMIC offers free after-hours message pads

At a minimum, document:

What Happened Here?

• Faulty Systems
• Differing Expectations
• Radiologist would call in report
• Communication Breakdowns
• No news is good news

Tracking

• Diagnostic tests
• Patient referrals
• Patients requiring follow-up
• “No-shows” or cancelled appointments

The Patient as a Safety Net

• Set expectations up front (Patient agenda)
• Disclose the diagnosis to the patient and what to expect
• Give the patient an approximate date to be notified
• Tell the patient to call back if s/he doesn’t hear back within

timeframe

• “No news” IS NOT “Good

news”!

• “We will call you with your
• results. If you don’t hear

from me or my office staff within 10 days, please call the office.”

Tracking Documentation

• Keep a paper log (example in book)
• EHR can track and send an alert/reminder
• Diagnostic tests or consultations
• Date the report is anticipated
• Date report received
• Patient notified and action taken
• Not filed until: provider review,

action taken, pt. notified

• Missed/cancelled appointments:
• Contact patient - # of attempts commensurate with

situation

• Contact referring physician (form in book)

EHR “The Sword”

• Copy/paste and cloned notes perpetuate

inaccurate or contradictory records

• Templates can lead to an inaccurate

diagnosis

• Position your EHR so it isn’t a barrier

between you and the patient

• Data display issues such as

hidden fields, multiple windows and need to scroll down or view a second page

EHR “The Shield”

• Decision support tools may help with

diagnosis

• Decrease errors in calculation, faulty memory
• Update problem lists, medications and allergies
• Legibility of notes
• Alerts (when not disregarded)
• Tracking, recalls and reminders
• Document patient education
• Create after-visit summary

Carryover Example

Two entries repeated at EACH VISIT for a 3 year period for cancer patient:

History: “patient was diagnosed with renal cancer 1 month ago” Medications: “no new medicines prescribed”

• Midlevel practitioners

Supervising Relationships Supervising Relationships

• Office Staff

Foster Collaborative Relationships

• Maximize staff to their

highest credentials

• Teach and appropriately

delegate to staff who then take ownership and initiative

• Staff huddles
• Encourage broader

situational awareness “Doctor, didn’t you want to repeat the CBC this visit?”

Team Participation

• Ensure important information gets relayed to the next

level of care

• “Front desk notifies nurse/MA that patient arrived short of

breath and mentioned he had some chest pain.”

• Be part of the safety net: Does what you see fit with the

medical diagnosis? If not, speak up.

• After-visit summary and

follow-up plans

• Use “teach-back” to ensure

patient understanding

• Provide take home

educational materials

• Call backs for follow-up

Midlevel Practitioner Supervision

• Physician or substitute physician must be

available for consultation at all times

• Must have experience and/or expertise in the

same area of medicine as the MLP

• Must authorize drugs on

the formulary

• Jointly developed protocols

Midlevel Practitioner Supervision

• Review a minimum of 20% of

records

• 100% review of records if

controlled substance prescription given

• Review within 10 days and certify

by signature within 30 days

• Visit remote sites every 30 days

All supervising physicians must:

Diagnostic Tools

• Evidence-based medicine (guidelines, clinical

protocols – document deviations)

• Today, there is at least one published protocol

for virtually every diagnostic category

• Recommendations

from specialty societies

• Agency for Healthcare

Research and Quality: www.guidelines.gov

• Error checklists

Use Comment/Narrative Field

A few sentences should be meaningfully used to:

• Document thought process, actions in response to event

being charted

• Document unexpected findings or unanticipated events
• Clarify an auto-populated entry that requires

explanation

• Explain “drop-down” entries that don’t quite fit

Coordinating Care

• Communication is key.
• You’re the primary care physician…
• Make sure all tests/consults are tracked back to you
• You’re the hospitalist…
• Make sure you know when and how to

hand-off the care back to the admitting physician

• You’re the consultant…
• Make sure you know who ordered the

consult, whether the report should be immediately communicated to the

• rdering physician and to whom you are

to transmit report

• Always tell the patient / family who is managing what condition.

Takeaways

• Complex Care is a team effort –

train to maximize staff

• Always construct a differential

diagnosis (What else could this be?)

• Not sure? keep looking…
• Obtain appropriate referrals or

second opinions

• Structure the handoff process
• Use decision support resources

Takeaways

• Consider diagnostic checklists
• Follow recommended screening

guidelines

• Ensure an efficient and effective

system of communicating abnormal and critical results clinician to clinician

• Improve the quality of your

documentation

• Partner with your patient and

remember communication is key!