diagnostic errors: management...

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© 2015 NORCAL Mutual Insurance Company

JANUARY 23, 2016TEXAS OSTEOPATHIC MEDICAL ASSOCIATION

DALLAS, TX

Presented by:BRADFORD S. DUNKIN, MHA

MARY-LYNN RYANRISK MANAGEMENT SPECIALISTS

Diagnostic Errors:A Risk Management Perspective


Faculty and Planners

Faculty► Bradford S. Dunkin, MHA

Sr. Risk Management Specialist

► Mary‐Lynn RyanRisk Management Specialist

Planners► Jo Townson

CME Manager/NORCAL

The faculty and planners of this activity have no relevant financial relationships to disclose.


DISCLAIMER

The information contained herein and presented by the speakers is based upon sources believed to be accurate at the time they were referenced.

The speaker is not engaged in rendering legal or professional services other than risk management. If legal advice is required, the services of an attorney should be sought.

This document was designed for discussion purposes only and is not intended to present detailed information on our analysis and findings. It is incomplete and not intended to be used without the accompanying oral presentation.

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Pre‐test questions

► 1: According to PIAA data from 2009‐2013, what type of malpractice claim resulted in the highest average indemnity payment?

► 2: Diagnostic errors are caused by:

A. Miscommunication

B. Breakdowns in follow up processes and care coordination

C. Errors in analytical thinking

D. Errors in intuitive reasoning

E. All of the above



► 3: Availability bias could result in which diagnosis error scenario:

A. Misdiagnosing a teenaged patient with influenza during flu season, when she had classic signs of bacterial meningitis (A: Availability bias)

B. Failing to diagnose cauda equina syndrome in a chronic back pain patient who kept returning to the ED with worsening back pain and saddle anesthesia. (A: Anchoring bias)

C. Failing to identify a scaphoid fracture after an ulnar fracture had been identified on the x‐ray of a car accident victim's arm. (A: satisfaction of search)



► 4. Research on the cognitive process of diagnosis indicates:

A. Physicians can access their memories for an almost unlimited set of diagnostic patterns.

B. There are steps physicians can take to reduce their diagnostic biases.

C. Physicians should try to decide on a patient’s diagnosis early in the assessment and then look specifically for signs and symptoms that support the diagnosis.

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Learning Objectives

By reviewing the key risk issues related to diagnostic error, this presentation will support your ability to:

► Identify risk management issues that contribute to diagnostic errors

► Evaluate your own practice risk exposures

►Apply risk management best practices to reduce the potential for diagnostic errors


What is Diagnostic Error?

“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.”

*Improving Diagnosis in Healthcare. Quality Chasm Series. Committee on Diagnostic Error in Healthcare. Erin P. Balogh, Bryan T. Miller, and John R. Ball, Editors. Board on Healthcare Services. Institutes of Medicine. September 2015.


Diagnostic Error

► 5% of U.S. adults who seek outpatient care

► 10% of patient deaths attributed to dx error

► 6% to 17% of adverse events in hospitals

*Improving Diagnosis in Healthcare. Quality Chasm Series. Committee on Diagnostic Error in Healthcare. Erin P. Balogh, Bryan T. Miller, and John R. Ball, Editors. Board on Healthcare Services. Institutes of Medicine. September 2015.

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Diagnostic Error

A frequent and expensive medical malpractice allegation.

► Failure to diagnose and incorrect diagnosis

►Average indemnity = $394,999*

► Paid‐to‐close ratio = 32.5%*

Compared to 26% for all claims

*PIAA Closed Claim Comparative, 2014 Edition. January 1, 2004 –December 31, 2013


Diagnostic Errors

• System Errors

• Cognitive Errors


System Errors

►Miscommunication

► Breakdown in Follow Up Processes

► Inadequate Supervision of Staff

► Inadequate Coordination of Care

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DISSECTING MEDICAL COGNITION

Intuitive Reasoning

Analytical Reasoning


Intuitive Thinking

► Compare information

Prior disease patterns

► Reflexive

Multi‐channeled

Efficient


Analytical Thinking

► Thoughtful

Consider potential diagnoses

Hypothesis testing

► Takes time

Need to collect and weigh data

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Integrating Intuitive and Analytical Thinking

► Benefits

► Limitations

► Biases


Common Biases

•Anchoring/Premature Closing

•Availability

•Emotional

•Representative Restraint

•Satisfaction of Search


ANALYSIS OF DIAGNOSTIC ERROR CLAIMS

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0 100 200 300 400 500 600 700 800 900

Medicine

Radiology

Surgery

Pediatrics/Neonatology

Pathology

Obstetrics/Gynecology

Physician Extenders

Emergency Medicine

Other

NUMBER OF CLAIMS

Specialties Involved in Diagnostic Error Claims

NORCAL Companies Claims Data 1/1/2010 ‐ 12/31/2014


Anchoring/Premature Closure Bias

Settling on a diagnosis early in the work‐up and discounting data

that do not fit.


Availability Bias

Focusing on the most readily available diagnosis, even if all of

the symptoms don’t fit.

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Emotional Bias

Diagnostic thinking influenced by the physician’s attitude about a

particular patient.


Representative Restraint Bias

Looking only for typical manifestations of an existing

illness.


Satisfaction of Search Bias

Stopping the search for a definitive diagnosis after finding one

explanation for the symptoms without considering comorbidities.

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Risk Management Recommendations

System and Cognitive Errors

Intuitive and Analytical Thinking

Differential Diagnosis

Consider Alternatives



Be Aware of Biases

Practice Time Outs

Reapproach

Utilize Clinical Guidelines


DIAGNOSTIC ERROR CLAIMSAGAINST MEDICINE

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Medicine / Medical Subspecialties

►Family Practice

►General Practice

► Internal Medicine

►All non‐surgical subspecialties

Allergy

Cardiology

Dermatology

Endocrinology

Et cetera


Top Five Associated Issues in Medicine Specialty Diagnostic Error Claims


Top Five Associated Issues –

Diagnostic Error Claims Against Medicine Specialties % of claims

1. Problems with history/exam/work‐up 35%

2. Failure to follow up 13%

3. Communication problems between HC providers 11%

4. Comorbid Issues 8%

5. X‐ray error 6%

5. Problems with records 6%


Incident Location – Medicine Specialty Claims

Practitioner's Office53%

Hospital35%

Nursing Home4%

Emergicenter3%

Hospital Outpatient Facility2%

Other3%


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Top Ten Conditions in Diagnostic Error Claims Against Medical Specialties


0

50

100

150

200

250


Case Study #1 – Breast Cancer

►40 year old female seen by PCP

Complaints of pain, swelling, tenderness in left breast

►Mammogram – inflammatory process, “no sign of cancer”

Antibiotics prescribed

►Pt. returned in one month

Continued complaints – same symptoms

Diagnosis – mastitis

Ordered a new antibiotic


Case Study #1 – Breast Cancer

►Pt. returned five weeks later

Diagnosis ‐ possible fat necrosis and costochondritis

Told to return in six months

►Eight months later – seen by gynecologist for worsening symptoms

Mammogram – suspicious for carcinoma

Confirmed by biopsy

►Patient underwent left mastectomy

7 of 12 positive lymph nodes

Patient died from metastatic disease

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Expert Reviews and Biases

• Radiologist

• PCPExpert

Reviewers

• Anchoring

• ContextDiagnostic

Error



Bias Awareness

Review Clinical Data

Pursue Ultimate Dx

Obtain Second Opinions


DIAGNOSTIC ERROR CLAIMSAGAINST RADIOLOGY

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Radiologists’ Role in Diagnosis

►Often do not have direct patient contact

►Need to discern:

Normal variants

Pathological lesions

Artifacts


Incident Location – Radiology Claims


► 92% of all claims against radiologists occur in the Radiology Department

24% occur in free‐standing radiology centers

►Where else do Radiology claims occur:

Emergency Departments – 4%

Physician’s office – 2%

Patient’s hospital rooms – less than 1%


Top Five Procedures Involved in Radiology Diagnostic Error Claims


Top Five Procedures –

Diagnostic Error Claims Against Radiologists % of claims

1. X‐rays 36%

2. CT Scans 29%

3. MRIs 11%

4. Mammography 9%

5. Ultrasound 9%

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Top Ten Conditions in Diagnostic Error Claims Against Radiologists


0102030405060708090

100


Case Study #2 – Lung Cancer

► 66 year old female

► Was in a motor vehicle accident

► Ordered: Spine, shoulder and chest x‐rays

► All studies interpreted as negative by ER physician

►Patient discharged

Dx: Left shoulder strain

►Films read by Radiologist next day

Noted variation but determined to be within normal limits


Case Study #2 – Lung Cancer

► Two years later Patient presented to PCP

Chief Complaint: Left arm pain and SOB

►Dx: Stage IV adenocarcinoma of lung

Metastasis to the brain

►Patient underwent radiation treatment and chemo

►Died 18 months after dx

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• Radiologist

• HospitalExpert

Reviewers

• Systems Error

• DelayDiagnostic

Error


Risk Management Recommendations ‐Radiology

Human Error Awareness

Continuing Education

Review/Comparison

Look/Judge Lesions


Risk Management Recommendations ‐Radiology

Display Resolution

Second Opinions

Further Studies

Positive Findings

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DIAGNOSTIC ERROR CLAIMSAGAINST SURGICAL SPECIALTIES


Surgery / Surgical Subspecialties

►General Surgery

►Cardiothoracic surgery

►Colorectal surgery

►Orthopedic surgery

►Et cetera


Top Five Associated Issues in Surgical Specialty Diagnostic Error Claims


Top Five Associated Issues –

Diagnostic Error Claims Against Surgical Specialties % of claims

1. Problems with history/exam/work‐up 32%

2. Communication problems between HC providers 12%

3. Unnecessary treatment 9%

4. X‐ray error 9%

5. Failure to follow up 8%

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Incident Location – Surgical Specialty Claims


Hospital45%

Practitioner's Office46%

Hospital Outpatient Facility5%

Surgicenter2%

Other2%


Most Prevalent Care Rendered in Surgical Diagnostic Error Claims


Most Prevalent Care Rendered–

Diagnostic Error Claims Against Surgical Specialties % of claims

1. Interview and Evaluation 38%

2. Consultation 23%

3. Eye Examination 9%


Top Thirteen Conditions in Diagnostic Error Claims Against Surgeons


0

10

20

30

40

50

60

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Case Study #3 – Undiagnosed Fracture

► 17 year old female

► Presented to ER with CC: Injured right ankle

►X‐Ray read:

Widening of medial ankle mortise

Soft tissue swelling

Ligament disruption

► Pt splinted

► Referred to Orthopedic Surgeon



► Orthopedic Surgeon dxd sprained right ankle

►Pt placed in walking cast

Weight bearing as tolerated

Return in one month

►At one month visit:

Cast removed

Replaced by brace

► Pain persisted an additional two months

► Second opinion from another orthopedic surgeon



►2nd Orthopedic Surgeon dxd:

Fracture separation of right ankle

Healing fracture of the proximal fibula

► Pt underwent ankle reconstruction

►Pt continues to have pain, weakness and tingling in her right leg

Walks with an abnormal gait

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• Additional x‐rays

• Non‐weight bearingExpert

Reviewers

• Failure to diagnose

• Failure to properly treatDiagnostic

Error


Risk Management Recommendations –Surgical Specialties

Be Aware of Biases

Establish Differential List

Follow Up System

Document Thoroughly


Risk Management Recommendations –Surgical Specialties

Effective Handoffs

Coordinate Referrals

Seek Additional Evaluation

Discharge Instructions

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RISK MANAGEMENT RECOMMENDATIONS TO IMPROVE CLINICAL REASONING, REDUCE ERRORS AND FOSTER DIAGNOSTIC ACCURACY


IOM Goals for Improvement

► Facilitate more effective teamwork

► Enhance education and training

► Ensure health IT supports the process

► Develop approaches to collect information on diagnostic error and near misses


IOM Goals for Improvement

►Establish a culture that supports improvement

►Develop a system that facilitates improvement

►Design care delivery and payment environments that supports the diagnostic process

►Provide dedicated research funding

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Diagnostic Time‐Outs

Seek Additional Information

Patient Education

Utilize Clinical Guidelines



Seek Diagnostic Error Rates

Consider Checklists

Use EHR Tools

Evaluate Personal Stresses



Consider Ongoing Symptoms

Consider Limits of Studies

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Address System Errors

Address Cognitive Errors

Mitigate Biases

In Summary


Post‐test questions

► 1: According to PIAA data from 2009‐2013, what type of malpractice claim resulted in the highest average indemnity payment?

► 2: Diagnostic errors are caused by:

A. Miscommunication

B. Breakdowns in follow up processes and care coordination

C. Errors in analytical thinking

D. Errors in intuitive reasoning

E. All of the above



► 3: Availability bias could result in which diagnosis error scenario:

A. Misdiagnosing a teenaged patient with influenza during flu season, when she had classic signs of bacterial meningitis (A: Availability bias)

B. Failing to diagnose cauda equina syndrome in a chronic back pain patient who kept returning to the ED with worsening back pain and saddle anesthesia. (A: Anchoring bias)

C. Failing to identify a scaphoid fracture after an ulnar fracture had been identified on the x‐ray of a car accident victim's arm. (A: satisfaction of search)

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► 4. Research on the cognitive process of diagnosis indicates:

A. Physicians can access their memories for an almost unlimited set of diagnostic patterns.

B. There are steps physicians can take to reduce their diagnostic biases.

C. Physicians should try to decide on a patient’s diagnosis early in the assessment and then look specifically for signs and symptoms that support the diagnosis.


Answers:

► 1: Error in diagnosis

► 2: E: All of the above

► 3: A is an example of availability bias, B is an example of availability bias and C is an example of satisfaction of search.


Answers:

► 4: B. Researchers who have investigated ways diagnostic decisions are made have found that, in order to make diagnoses, physicians compare information from each presenting patient with disease patterns they have memorized. However, researchers have also found that because clinicians can hold only a limited set of considerations in mind at any given moment, they must make continuing decisions about what is important, which can bias their decision making. Learning about various types of common biases, such as “premature closure” (coming to a diagnostic decision very early in the assessment and then disregarding signs and symptoms that don’t match that diagnosis) can help physicians avoid being erroneously influenced by them. The confines of human thought make it impossible to completely eliminate all errors in diagnosis.

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Q & A


Bradford S. Dunkin, MHASr. Risk Management Specialist

NORCAL Mutual800‐652‐1051, ext. 1580

bdunkin@norcal‐group.com

Mary‐Lynn RyanRisk Management Specialist

NORCAL Mutual800‐652‐1051, ext. 2045mryan@norcal‐group.com

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