diagnostic error in medicine
DESCRIPTION
Cognitive bias in clinical reasoningTRANSCRIPT
Improving Diagnosis
• Cognitive bias
• Dr.Lorenzo Alonso
• Foro Osler: www.foro-osler.com
Adverse events: 3,7% : 14% deaths
27% malpractice: 75% diagnostic problem.
Most common medical errors
Error: ¿Why?
ERROR
System
-Work place
-Communicatión
-Alerts
Individual
-fatigue, strees,..
- reasoning
- experience
- metacognition
System and Diagnosis
An 35 y/o man went to ED Referring back pain and
paraparesia
He went twice to the ED.
No one asked.. And couldn,t retrieve medical
record
At that moment was impossible to track a diagnosis of melanoma two
years before
Doctor´s mind: a young Person can,t have
An importantdisease
SYSTEM
Cognitive
JAMAVolume 301(10)
March 11, 2009Copyright 2009 by the American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use. American Medical Association, 515 N. State St, Chicago, IL 60610.
ISSN: 0098-7484
Diagnostic errors: Definition
• Diagnostic never made.
• Wrong Diagnostic.
• Late Diagnostic.
Diagnostic error compound
More automatic:
More experience
More analysis
Slower
Less experience
Wrong mentalreasoning
Lack ofInformation.Rethinking
Two Systems of reasoning (Croskerry)
Examples of Cognitive errors (heuristics)
Next cartoons extracted from: Sox. Clinical Decision Making. Butterworth-Heineman 1988.
Representation heuristics
Endocrinologist think
About Cushing in a patient with high BP and hirsutism (non prevalent)
Availability
The intern saw two
Splenic abscess in the previous rotation. Now he thinks that there is another one in front
Of him.
Premature closing
I don,t have the biopsy but anyway, he just came
with fever.
Overconfidence
Framing: to put labels on people
Case 1
• A patient with a diagnosis of CPOD started with pain and shock during the night. The Hemoglobin levels were around 14. No one thought about bleeding: but he was polycitemic and his previous Hemoglobin levels were over 18..
Retroperitoneal Hematoma
Hb
13/5/08
19
18/05
17,5
19/05
16,5
21/05
15
22/05/10
14,5
System Failure:”:Communicatión
Organizatión informatión
Case 2
• An old man went to the ED after a fall. At the hand recors some doctor wrote: right arm thrombosis
• Next day the right arm was paretic.
Pancoast tumor : 5% lung cancer
Horner Syndrom: 14-50% of cases.
Framing: old people felt down .. Because they felt down
Premature closing: no one examine the information about the previous diagnosis.
Recipe to improve diagnostic abilities
• Common sense
• Method
• Study
• Teamwork
• Metacognition: to know how we think.
Fish bone diagram to study the systems aspects related to diagnosis
FAILURETEAM
Communicatión
Coordinatión
Training
PROCESS
Not specified
Lack of material
No supervisión
Bad asignament
Wrong test
ROLES
Wrong evaluation of urgency
Complications
No alerts
Inefficient summary of data
COGNITIVE
COMPOUND
(Checklist)
Dr. M. Graber
IMPROVEMENT AND CHANGE IS POSSIBLE