Welcome to the Mount Auburn Practice Improvement Program

Welcome to the Mount Auburn Practice Improvement Program

Welcome to the Mount Auburn Practice Improvement Program Community Learning Session Please be sure to sign in! Understanding and Preventing Diagnostic Errors in Medicine Mount Auburn Practice Improvement Program March 4, 2016 Gordon Schiff MD

Associate Director Center for Patient Safety Research and Practice Brigham and Women's Hospital Div. General Medicine Safety Director Harvard Center for Primary Care Academic Innovations Collaborative Associate Professor of Medicine Harvard Medical School Financial Conflicts/Disclosures Commercial None related (Medware data-mining project)

Other/Grant Funding AHRQ PROMISES Ambulatory Safety & Malpractice AHRQ CERT: BWH CERT HIT Drug Reaction detection Chicago (UIC/NW) Patient Safety CERT FDA - CPOE Errors Evaluation (CPOEMS) CRICO Diagnostic Errors/Pitfalls Grant Gold / Leape Foundation- Boundaries Issues 3 Learning Objectives As a result of participating in this session,

learners will be able to: Describe the key drivers of diagnostic failure Explain how cognitive error contributes to late or incorrect diagnoses Identify practical strategies to prevent diagnostic error in the ambulatory setting IOM Quality Reports IOM Report September

2015 8 IOM Goals to Improve Diagnosis and Reduce Diagnostic Error GOAL 1 Facilitate more effective teamwork in the diagnostic process among health care professionals, patients, and their families GOAL

2 Enhance health care professional education and training in the diagnostic process GOAL 3 Ensure that health information technologies support patients and health care professionals in the diagnostic process

GOAL 4 Develop and deploy approaches to identify, learn from, and reduce diagnostic errors and near misses in clinical practice 8 IOM Goals to Improve Diagnosis and Reduce Diagnostic Error GOAL 5

Establish a work system and culture that supports the diagnostic process and improvements in diagnostic performance GOAL 6 Develop a reporting environment and medical liability system that facilitates improved diagnosis through learning from diagnostic errors and near misses GOAL

7 Design a payment and care delivery environment that supports the diagnostic process GOAL 8 Provide dedicated funding for research on the diagnostic process and diagnostic errors

Don Berwick Formerly President and CEO Institute for Healthcare Improvement (IHI) Director Centers for Medicare & Medicaid Services MA Governor Candidate 9

Genius diagnosticians make great stories, but they don't make great health care. The idea is to make accuracy reliable, not heroic Don Berwick Boston Globe 7/14/2002 10 YOUR PERSONAL EXPERIENCES

14 Schiff et al JAMA Intern Med 2013 17 18 ONLY ~50-50 chance this order results in colonoscopy actually

being performed ! 19 What went wrong: DEER Taxonomy Localization 21 Failure to Consider: Cognitive vs. System Problem?

Why did clinician fail to consider? Lack knowledge, memory recall Inadequate time Failure to elect key hx or physical Competing diagnoses, symptoms Rare, atypical Tests threw off Distractions What are the causes? Biases; heuristic What are the remedies?

22 What is a Diagnosis Error? Adverse Outcomes Diagnostic Process Failures

Delayed, Missed, Misdiagnosis Modified from Schiff Advances in Patient Safety AHRQ 2005, Schiff & Leape Acad Med 2012 2 Key Improvement Concepts Situational Awareness Safety Nets

Diagnostic Risk Situational Awareness Specialized type of situational awareness High reliability organizations/theory High worry anticipation of what can go wrong Preoccupied w/ risks recognizing/preventing Appreciation diagnosis uncertainty, limitations Limitations of tests, systems vulnerabilities Knowing when over head need for help

Making failures visible Dont miss diagnoses, red flag symptoms Diagnostic pitfalls potentially useful construct 25 Perhaps the most important distinguishing feature of high-reliability organizations is their collective preoccupation with the possibility of failure. They expect to make errors and train their workforce to recognize and recover them. They continually

rehearse familiar scenarios of failure and strive hard to imagine novel ones. Instead of isolating failures, they generalize them. Instead of making local repairs, they look for system reforms Reason Human error: models and management West J Med. 2000; What is a Diagnostic Pitfall? Clinical situations where patterns of, or vulnerabilities

to errors leading to missed, delayed or wrong diagnosis Diagnostic Pitfalls Overall aim: develop new construct diagnostic pitfalls then test ways to electronically screen Examples of diagnostic pitfalls include: Failure to pursue further evaluation of breast lump in light of normal mammogram Attributing rectal bleeding to hemorrhoids Failure to take seriously symptoms in patient with

underlying psychosocial problems Stasis dermatitis misdiagnosed as bilateral cellulitis Pitfalls Project: Preliminary Results Generic Diagnostic Pitfall Paradigms -Disease A repeatedly mistaken for Disease B Bipolar disease mistaken for depression

-Failure to appreciate test/exam limitations Limitation of CT to diagnose subarachnoid hemorrhage after time -Atypical presentation Addisons disease presenting with weight loss, cognitive difficulties, fatigue

-Presuming chronic disease accounts for new symptoms Delay in initiating work-up for clinical clues suggestive of lung cancer in patients with hypertension and COPD -Failure to monitor evolving symptom Pts w/ subdural hematoma, cranial imagining can be normal

shortly after incident, but chronic subdural later develops Unified Model of Diagnostic Situational Awareness Heuristic or Bias What is difference between a bias and a heuristic Very efficient mental short-cut that most often gets you to the right diagnosis Vs. something that leads you astray, sending down wrong path or causes you to get stuck

on wrong diagnosis If "heuristics" is packaged wisdom, then is "bias" simply short circuited logic? Evolutionary advantage of bias? Schiff & Graber Diagnosis Errors in Acute Care Setting. Principles and Practice of Hospital Medicine McGraw H Diagnostic Risk Safety Nets

Recognizing inherent uncertainties/risks, build in mitigation, protections, recovery structures and processes Proactive, systematic follow-up, feedback via closed loop systems Major role for HIT to hard-wire To automate, ensure reliability, ease burden on staff/ memory, ensure loops closed and outliers visible 35 Principles for Leveraging, Learning,

Lessening Diagnostic Error in Medicine Reliance on memory New science of diagnostic uncertainty Linkages Dx & Rx

Leverage HIT Re-engineering diagnosis as a system Diagnostician of future 37 El-Kareh Schiff BMJ QS 2013 38

With Electronic Medical Records, Doctors Read When They Should Talk Abigail Zuger New York Times 10/13/2014 Will history someday show that the electronic medical record almost did the great state of Texas in? We are in the middle of a simmering crisis in medical data management. Like computer servers everywhere, hospital servers store great masses of trivia mixed with valuable information and gross misinformation, all cut and pasted and endlessly reiterated

There is no time to dig and, even worse, no time to do what we were trained to do slow down, go to the source, and start from the beginning. http://www.physiciansfoundation.org/uploads/default/2014_Physicians_Foundation_Biennial_Physician_Survey_Report.pdf 42 43 Priority to rapidly

improve EHR usabilty and functionality 44 45 Role for Electronic Documentation

Goals and Features of Redesigned Systems Providing access to information Ensure ease, speed, and selectivity of information searches; aid cognition through aggregation, trending, contextual relevance, and minimizing of superfluous data. Recording and sharing assessments

Provide a space for recording thoughtful, succinct assessments, differential diagnoses, contingencies, and unanswered questions; facilitate sharing and review of assessments by both patient and other clinicians. Maintaining dynamic patient history Carry forward information for recall, avoiding repetitive pt querying and recording while minimizing erroneous copying and

pasting Maintaining problem lists Ensure that problem lists are integrated into workflow to allow for continuous updating. Tracking medications Record medications patient is actually taking, patient responses to medications, and adverse effects to avert misdiagnoses and

ensure timely recognition of medication problems. Tracking tests Integrate management of diagnostic test results into note workflow to facilitate review, assessment, and responsive action as well as documentation of these steps. Clinical Documentation CYA

Canvass for Your Assessmen t -Differential Diagnosis -Weighing Likelihoods -Etiology

-Urgency -Degree of certainty Canvass for Your Assessment Role for Electronic Documentation

Goals and Features of Redesigned Systems Ensuring coordination and continuity Aggregate and integrate data from all care episodes and fragmented encounters to permit thoughtful synthesis. Enabling follow-up Facilitate patient education about potential red-flag symptoms;

track follow-up. Providing feedback Automatically provide feedback to clinicians upstream, facilitating learning from outcomes of diagnostic decisions. Providing prompts Provide checklists to minimize reliance on memory and directed questioning to aid in diagnostic thoroughness and problem

solving. Providing placeholder for resumption of work Delineate clearly in the record where clinician should resume work after interruption, preventing lapses in data collection and thought process. Schiff & Bates NEJM 2010

Open Loop System Schiff A J Med 2008 51 Open Loop System Water goes on the same time each day, regardless of whether it is raining or lawn is

flooded Schiff A J Med 2008 52 53 54 55/338 (16%) not improved of whom only 21 (38%)

had contacted any clinician 55 Feedback Key Role in Safety Structural commitment patient role to play Embodies/conveys message: uncertainty, caring, reassurance, access if needed Allows deployment of test of time, more conservative diagnosis Enables differential diagnosis

Emphasizes that disease is dynamic Reinforces culture of learning & improvement Illustrates how much disease is self limited Makes invisible missed diagnoses visible 56 Examples of Feedback Learning Feeding back to upstream hospital - spinal epidural abscess IVR follow-up post urgent care visit - UAB Berner project

Chart correction by patients Radiology/pathology - systematic second reviews Dedicated Dx Error M&M 2nd opinion cases - Best Doctors dx changed Autopsy Feedback

- 7/32 MDs aware disseminated CMV Linking lab and pharmacy data - to find signal of errors (missed TSH) ED residents post admission tracking Urgent care - call back f/up systems Feedback to previous service

Malpractice - knock on the door Tracking persistent mysteries 57 Feedback- Challenges

Effort, time, support required Discontinuities Can convey non-reassuring message Feedback fatigue Non-response not always good predictor of misdiagnosis as multiple confounders Tampering form of availability bias

58 Diagnosis Essentials Checklist 1. Essential Data Elements - Elements of Hx, P.exam, tests data that should be reliably obtained for every pt presenting with given sx. In many situations can reliably be done w/ computer questionnaire. 2. Dont miss diagnoses critical dx can present w/ sx that are fatal or have serious consequences if not recognized and rx promptly. These dx should be considered in every patient with that symptom. 3. Red flag symptoms- sx or findings (e.g. back pain with new urinary

incontinence in cancer patient) that may indicate serious condition & should lead to heightened suspicion/evaluation for dont miss dx. Schiff & Leape Acad Med 2012 Schiff BMJ Safety & Qual 2012 59 Fatigue Checklist (27 diagnoses) Prevalenc

e Obstructive sleep apnea Depression, anxiety Deconditioning *Drugs (beta blocker, clonidine, alcohol) Chronic fatigue syndrome, fibromyalgia *Infections, infectious mononucleosis, hepatitis, pneumonia, mastitis Pregnancy *Anemia Vitamin D deficiency

Hypothyroidism, hyperthyroidism Hypokalemia, hyponatremia *Myocardial infarction Dont Celiac disease Disturbance of calcium, phosphorus, magnesium * Often Polymyalgia rheumatica/Temporal arteritis missed Parkinson disease Hypogonadism

Myasthenia gravis *Heart failure, myocarditis Pulmonary, hepatic, renal failure Restless legs syndrome Multiple sclerosis Carbon monoxide Adrenal insufficiency, Addisons disease B12 deficiency Botulism Black widow spider bite Ely Acad Med 2010

miss Diagnosis Essentials Checklist 4. Potential drug causes meds that can cause the symptom. High % sx med side effects, yet infrequently considered. 5. Required referrals - When is specialist expertise or technology needed to adequately and safely evaluate the patient? Includes possible rare conditions that only specialists have sufficient experience or where required testing (biopsy or endoscopy) 6. Patient follow-up instructions and plan - Warnings that patients

should receive regarding specific symptoms that should lead them to return or call. These should be in writing and include a time frame. (e.g. call if you develop rash or fever, or if you are not improved in 48 hours) Schiff & Leape Acad Med 2012 Schiff BMJ Safety & Qual 2012 61 3rd generation Dx support

Cerner with Isabel integration Role for Electronic Documentation Goals and Features of Redesigned Systems Calculating Bayesian probabilities

Embed calculator into notes to reduce errors and minimize biases in subjective estimation of diagnostic probabilities. Providing access to information sources Provide instant access to knowledge resources through contextspecific info buttons triggered by keywords in notes that link user to relevant textbooks and guidelines. Offering second opinion or consultation

Integrate immediate online or telephone access to consultants to answer questions related to referral triage, testing strategies, or definitive diagnostic assessments. Increasing efficiency More thoughtful design, workflow integration, easing and distribution of documentation burden could speed up charting, freeing time for communication and cognition.

Schiff & Bates NEJM 2010 Role for Patient In Minimizing and Preventing Diagnosis Error and Delay

Push for timely access Reliable follow-up, continuity Keen observer, reporter sx Proactive on test results Sharing hunches Curiously reading on own Meticulously adhering w/ empiric trial regimens Active as co-investigator

Being patient: time & tests Recruiting family for support Respecting limits on staff time, society resources Agreeing to disagree Help in building, maintaining trust and communication Getting involved with patient organizations 65

Role for Patient In Minimizing and Preventing Diagnosis Error and Delay

Push for timely access Reliable follow-up, continuity Keen observer, reporter sx Proactive on test results Sharing hunches Curiously reading on own Meticulously adhering w/ empiric trial regimens Active as co-investigator Being patient: time & tests

Recruiting family for support Respecting limits on staff time, society resources Agreeing to disagree Help in building, maintaining trust and communication Getting involved with patient organizations Key question is: What will it take at the provider and institutional end

to support these roles and help them flourish? 66 67 Ricardo Levins Morales Art Studio

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