Diagnostic error is increasingly recognised as a significant problem - - PowerPoint PPT Presentation

Take 2 – Think, Do

Tracy Clarke Deputy Director Governance and Assurance

2 minutes to confirm your diagnosis, double check or ask for a second opinion

Diagnostic error is increasingly recognised as a significant problem globally

• Analysis of diagnostic error in NSW has included

– IIMS data for 2012 and 2013 – RCAs for 2012 – 2014 – CHASM for 2011 – 2013

Harm to patients

What we know

• There are patient deaths in NSW a directly

attributable to a diagnostic error

• Error occurs across all clinical groups

What we don’t know

• What is the degree of inconvenience and minimal

harm to patients

• The degree of impact on time to treatment /

progression of disease / length of stay

• What is the overall cost to health care in NSW?

Why diagnostic errors occur

• System 1 Vs System 2 thinking
• Red flags / pattern recognition aren’t perfect
• Easy to unconsciously shift into intuitive /fast

thinking:

– Fatigue - 30% decrease in cognition at end of a night shift – Cognitive overload – Task interruption – Sick, depressed, angry

• JMOs don’t have well developed red flag system

– Junior staff need to be taught to be in slow thinking lane most of the time

(Pat Crosskerry “The Importance of Cognitive Errors in Diagnosis and Strategies to Minimize Them”)

The CEC program

AW

Take 2 – Think, Do

To support accurate diagnostic decision making in busy clinical environments by promoting a quick reflection on the diagnostic process and enhancing recognition of high risk situations where a closer examination of the information available is warranted

While deliberating the diagnosis:

• Document the

differential diagnoses

• Detect any ‘red flag’

symptoms

• Acknowledge

uncertainty in diagnostic dilemmas

• Rule out the worst

case scenario

• Identify when

something isn’t quite right

Take 2 minutes to deliberate the diagnosis Think about situations when it may be necessary

to take a closer look or re-evaluate the diagnosis

Take a closer look when:

There are risk factors impacting diagnostic decision making:

• HALT (Hungry, Angry, Late, Tired)
• Cognitive biases (e.g. context,

framing bias)

• Patient engagement difficulties
• Knowledge deficit or workload

pressures

Facility or specialty specific high risk presentations - Take 2 for you

Take time to review at specific patient journey checkpoints:

• Things aren't going as planned
• The patient is deteriorating
• The expected response to

treatment is not achieved

• At handover between teams

and discharge from care

• The patient or carer is expressing

concern over the diagnosis

Do something to take a

closer look and review the diagnosis

Strategies to review and challenge the diagnosis:

• Individual strategies
• eg. Diagnostic Time-
• ut
• Team based strategies
• eg. Red Team Blue

Team Challenge

• Seek a second opinion
• Refer to specialist

services

• Escalate care for senior

medical officer evaluation and input

• The worst case scenario is

ruled out

• Atypical or rare

presentations are identified

• There is a high suspicion for

repeat presentations

• Diagnosis is re-evaluated

when things aren’t quite right

• The patient and carers’

concerns are heard and acknowledged

• Locally identified high-risk

patient groups are recognised

• There is an environment that

enables discussion around diagnosis

• There is appropriate referral

and escalation for diagnostic dilemmas

• There is effective

communication when transferring care

Outcomes

Think about situations when it may be necessary

to take a closer look or re-evaluate the diagnosis

Take a closer look when:

There are risk factors impacting diagnostic decision making:

• HALT (Hungry, Angry, Late, Tired)
• Cognitive biases (e.g. context,

framing bias)

• Patient engagement difficulties
• Knowledge deficit or workload

pressures

Facility or specialty specific high risk presentations - Take 2 for you

Take time to review at specific patient journey checkpoints:

• Things aren't going as planned
• The patient is deteriorating
• The expected response to

treatment is not achieved

• At handover between teams

and discharge from care

• The patient or carer is expressing

concern over the diagnosis

Do something to take a

closer look and review the diagnosis

Strategies to review and challenge the diagnosis:

• Individual strategies
• eg. Diagnostic Time-
• ut
• Team based strategies
• eg. Red Team Blue

Team Challenge

• Seek a second opinion
• Refer to specialist

services

• Escalate care for senior

medical officer evaluation and input

• The worst case scenario is

ruled out

• Atypical or rare

presentations are identified

• There is a high suspicion for

repeat presentations

• Diagnosis is re-evaluated

when things aren’t quite right

• The patient and carers’

concerns are heard and acknowledged

• Locally identified high-risk

patient groups are recognised

• There is an environment that

enables discussion around diagnosis

• There is appropriate referral

and escalation for diagnostic dilemmas

• There is effective

communication when transferring care

Outcomes

While deliberating the diagnosis:

• Document the

differential diagnoses

• Detect any ‘red flag’

symptoms

• Acknowledge

uncertainty in diagnostic dilemmas

• Rule out the worst

case scenario

• Identify when

something isn’t quite right

Take 2 minutes to deliberate the diagnosis

While deliberating the diagnosis:

• Document the

differential diagnoses

• Detect any ‘red flag’

symptoms

• Acknowledge

uncertainty in diagnostic dilemmas

• Rule out the worst

case scenario

• Identify when

something isn’t quite right

Take 2 minutes to deliberate the diagnosis Do something to take a

closer look and review the diagnosis

Strategies to review and challenge the diagnosis:

• Individual strategies
• eg. Diagnostic Time-
• ut
• Team based strategies
• eg. Red Team Blue

Team Challenge

• Seek a second opinion
• Refer to specialist

services

• Escalate care for senior

medical officer evaluation and input

• The worst case scenario is

ruled out

• Atypical or rare

presentations are identified

• There is a high suspicion for

repeat presentations

• Diagnosis is re-evaluated

when things aren’t quite right

• The patient and carers’

concerns are heard and acknowledged

• Locally identified high-risk

patient groups are recognised

• There is an environment that

enables discussion around diagnosis

• There is appropriate referral

and escalation for diagnostic dilemmas

• There is effective

communication when transferring care

Outcomes Think about situations when it may be necessary

to take a closer look or re-evaluate the diagnosis

Take a closer look when:

There are risk factors impacting diagnostic decision making:

• HALT (Hungry, Angry, Late, Tired)
• Cognitive biases (e.g. context,

framing bias)

• Patient engagement difficulties
• Knowledge deficit or workload

pressures

Facility or specialty specific high risk presentations - Take 2 for you

Take time to review at specific patient journey checkpoints:

• Things aren't going as planned
• The patient is deteriorating
• The expected response to

treatment is not achieved

• At handover between teams

and discharge from care

• The patient or carer is expressing

concern over the diagnosis

While deliberating the diagnosis:

• Document the

differential diagnoses

• Detect any ‘red flag’

symptoms

• Acknowledge

uncertainty in diagnostic dilemmas

• Rule out the worst

case scenario

• Identify when

something isn’t quite right

Take 2 minutes to deliberate the diagnosis Think about situations when it may be necessary

to take a closer look or re-evaluate the diagnosis

Take a closer look when:

There are risk factors impacting diagnostic decision making:

• HALT (Hungry, Angry, Late, Tired)
• Cognitive biases (e.g. context,

framing bias)

• Patient engagement difficulties
• Knowledge deficit or workload

pressures

Facility or specialty specific high risk presentations - Take 2 for you

Take time to review at specific patient journey checkpoints:

• Things aren't going as planned
• The patient is deteriorating
• The expected response to

treatment is not achieved

• At handover between teams

and discharge from care

• The patient or carer is expressing

concern over the diagnosis

• The worst case scenario is

ruled out

• Atypical or rare

presentations are identified

• There is a high suspicion for

repeat presentations

• Diagnosis is re-evaluated

when things aren’t quite right

• The patient and carers’

concerns are heard and acknowledged

• Locally identified high-risk

patient groups are recognised

• There is an environment that

enables discussion around diagnosis

• There is appropriate referral

and escalation for diagnostic dilemmas

• There is effective

communication when transferring care

Outcomes Do something to take a

closer look and review the diagnosis

Strategies to review and challenge the diagnosis:

• Individual strategies
• eg. Diagnostic Time-
• ut
• Team based strategies
• eg. Red Team Blue

Team Challenge

• Seek a second opinion
• Refer to specialist

services

• Escalate care for senior

medical officer evaluation and input

The Red Team / Blue Team Challenge

• Designating an individual to play the role of Devil’s

Advocate

• Assists in challenging authority gradients – sets an

expectation on JMO to question , and SMO to explain

• Incentive – Goal to improve teaching, supervision and

a shared mental model within a team – may improve diagnostic accuracy

• Proximity to patients – care or explanation required

The Red Team Blue Team Challenge

Key components:

• There is a safe environment before

starting

• Scripted start and conclusion to

Challenge

• Red Team prompts for

consideration

• Flexibility to suit facility and unit

structures

• Opportunities to challenge
• Where the challenge takes

place

When to Consider ?

• Not every patient every time, but consider

– Points in the patients journey

• new admissions on transfer to the ward,
• as well as those requiring special review
• Before discharge
• Things aren’t going as planned

– Deteriorating patient

• Part of the response team follow-up after a rapid response call

Contacts

Tracy Clarke – Deputy Director Governance and Assurance Tracy.Clarke2@health.nsw.gov.au

• Ph. 02 9269 5626

Paul Curtis – Director Governance and Assurance Paul.Curtis@health.nsw.gov.au

Acknowledgements:

A/Prof Amanda Walker – Clinical Advisor ACQSHC