Teaching About Medical Error

Deirdre BonnycastleMay 2009

ObjectivesUpon completion of this session, you will be

able to:

1. Identify types of medical learner errors

2. Name cognitive errors

3. Create a strategy for dealing with each type of error.

“In Canada the number of people who die from

adverse events in the health care system each

year has been estimated to be up to 25,000.”P. Croskerry

Dalhousie College of Medicine

“It may seem a

strange principle to

enunciate but the very

first requirement in a

hospital is that it

should do the sick no

harm.”

• Florence Nightingale

Saskatchewan Girl Case

Week One21 year old complaining of chest pain and fatigue, mild respiratory distress, family doc left without referring patients, so went to minor emergency clinic• upon examination, there is heart arrhythmia• patient is send to emergency by ambulance• two hours later, heart is normal• referred to heart specialist• told to not work for two weeks

What did the FM and ER not do?

At this point what basic

information is missing and

crucial to the case?

Two Week CostTo Patient

$300 ambulance $1500 lost wages

To Medicare $ FM $ ER $ Tests

Week Three and FourPatient is examined by specialist • no heart problem identified• probably stress note on report

Patient sees original doctor • no examination• given anti-stress drugs

Four Week Cost

To Patient $300 ambulance $3000 lost wages $70 prescription cost

To Medicare $ FM $ Specialist $ ER $ FM $ Tests

Week Five

Patient has a temperature of 103, the pain in her

chest and difficulty breathing is worse. She goes

to a different doctor

diagnosis severe pleurisy given weekly injection of antibiotics suspicion of lung scarring told not to return to work for at least three weeks

Final CostTo Patient

$300 ambulance $6000 lost wages = stress at home and work $70 inappropriate prescription cost

To Medicare $ FM $ Specialist $ Tests $ FM $ ER $ FM $ FM $ FM $ Tests $ FM $ Antibiotics

Reflect on the errors and

we will re-examine this

case later.

Identify types of medical learner errors

1. Incomplete Knowledge

2. Poor Technique

3. Cognitive Error

4. Systemic Error

Name cognitive errors

Categories of Cognitive Errors

1. Confirmation Bias

2. Attribution Errors

3. Commission Bias

4. Investigation Errors

For more information, seehttp://blogs.usask.ca/medical_education/archive/2007/05/teaching_about.html

Why is it difficult to give students feedback

on cognitive errors?

How might being able to name the type of

cognitive error help?

This prevalent cultural pattern—discussing knowledge in groups large and small, but applying it as individual practitioners—is perfectly designed to delay the implementation of new knowledge and to produce wide variation in practice.

Systemic Error

Zen and the Art of Physician Autonomy Maintenance - Reinertsen Ann Intern Med. 2003

Variation adds complexity

— to the work of nurses, pharmacists, and physicians who share in the care of our patients.

— a breeding ground for errors

In the initial case, how would you diagnose the

types of errors?

In the initial case, how would you diagnose the

types of errors?

• Systemic no referral to new physician when old left

• Cognitive Confirmation bias -looking only for heart

problem Attribution errors -female must be stressed Investigation errors -not doing a complete

examination -allowing heart specialist to diagnose stress (framing effect)

Create a strategy for dealing with each type of error.

Knowledge Errors

How might Illness Scripts assist students to identify gaps in their knowledge?

How might you use the SNAPPS technique to identify gaps in knowledge?

For more information, see http://medicaleducation.wetpaint.com/page/Thinking+like+a+Physician

Errors in Technique

How might errors in technique be monitored?

What role does checklists play in improving technique?

What other strategies might you implement?

“See one, do one, teach one” training ended at Dalhousie more than a decade ago. Today’s Dalhousie residents receive skills training and

responsibilities, carefully graduated and monitored over the course of their residencies.” P. Croskerry

Cognitive Error

How can the 5 minute preceptor assist you to identify cognitive errors.

How might chart reviews help identify errors?

How else might you build in safeguards in this area?

For more information see http://medicaleducation.wetpaint.com/page/Thinking+like+a+Physician

Systemic Error

How could you help students recognize the

difference between personal and systemic

errors?

How could the teaching of patient advocacy and

recognition of systemic errors be combined?

Dr. Pat Croskerry’s suggestions• Provide detailed descriptions and thorough

characterizations of known Cognitive and Affective errors

• Establish forced consideration of alternative possibilities

• Train for a reflective approach to problem-solving

• Develop generic and specific strategies

• Identify specific flaws and biases in thinking and provide directed training to overcome them

• Develop mental rehearsal, “cognitive walkthrough” strategies for specific clinical scenarios

P. Croskerry continued• Improve the accuracy of judgments through

cognitive aids

• Provide more information about the specific problem

•

• Provide adequate time for quality decision-making

• Establish clear accountability•

• Improve feedback and feed forward

- Diagnostic Failure: A Cognitive and Affective Approach

Resources online

P. Croskerry Diagnostic Failure: A Cognitive and Affective Approach http://www.ncbi.nlm.nih.gov/books/bv.fcgi?highlight=Croskerry&rid=aps.section.2444

Medical Education Blog http://blogs.usask.ca/medical_education/archive/2007/05/teaching_about.html

26 Reasons What You Think is Right is Wronghttp://www.blisstree.com/healthbolt/26-reasons-what-you-think-is-right-is-wrong/

Cognitive distortionhttp://en.wikipedia.org/wiki/Cognitive_distortion

Print Resources

Croskerry, P. (2003) When diagnoses fail, The Canadian Journal of CME: 79-87

Crosskerry, P. (2003)The importance of cognitive errors in diagnosis and strategies to minimize them. Academic Medicine: 78(8):775-780

Groopman, J. (2007) How doctors think, Houghton MifflinMazor, K. et all (2005) Teaching and medical errors

Medical Education Journal:39:982-990Montgomery, K.(2006) How Doctors Think: Clinical

Judgment and the Practice of Medicine, Oxford University Press

Redelmeir D. (2005) The cognitive psychology of missed diagnoses Annals of Internal Medicine Volume 142 Issue 2 | Pages 115-120

Thank You