The Role of the RN and APRN in Addressing Diagnostic Error

Transcription

1 The Role of the RN and APRN in Addressing Diagnostic Error Mark L. Graber, MD, FACP Founder and President SIDM Senior Fellow RTI International Professor Emeritus Stony Brook University, NY

2 Society to Improve Diagnosis in Medicine VISION: We envision a world where diagnosis is accurate, timely, efficient, & SAFE; where no patients are harmed by diagnostic error. 2

3 . Who Am I?

4 Thomas Duncan US Ebola Patient #1 Pt presented to ER with fever, nausea, & headache; Recent travel to Liberia noted by RN triage nurse, documented in the EHR Pt seen by MD: MD not aware of RN s history Dx = Sinusitis; Discharged to home 24 people exposed to Ebola in the next 2 two weeks before he died

5 Objectives How likely is diagnostic error? What are the major causes? (How do doctors think?) What can we do about this? How can RN s and APRN s improve diagnosis?

6 Rory Staunton Wednesday: 3 days earlier: Scraped arm Wakes from sleep: Fever, chills, vomiting Thursday Worse; Pediatrician: T102; HR 140; RR36; BP 100/60 Skin: mottled; Abd benign ASSESSMENT: Gastroenteritis Call made to ER

7 Thursday, 9 PM Emergency Dept PE: T 100; HR 143; RR 20; BP 94/46 Abd benign; No skin exam documented ASSESSMENT: Gastroenteritis PLAN: ondansetron, NS IV 1 L, home LABS: (Return after discharge): WBC 14.7; 53% bands

8 Friday: Worse; Skin sensitive to touch, turning splotchy and blue with red spots Family calls pediatrician multiple times: Advised acetaminophen Saturday: Returns to ER, admitted to ICU; Dx = Streptococcal sepsis. Sunday: Dies in the ICU

9 Knowing is not enough, we must apply Willing is not enough, we must do All of Us Recommendations Practice Improvement

10 Definition of 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 The single biggest problem in communication is the illusion that it has taken place. George Bernard Shaw

11 Think about yourself and your family: Can you recall when a diagnosis you were given was wrong? Can you recall when a diagnosis could have been made much earlier? Is there someone with a medical condition that is still causing symptoms but hasn t been diagnosed? NPSF Survey 2017: One in five Americans has experience with a medical error and the most common reason is misdiagnosis

12 Claims Data: High-severity Cases Top allegation category: Diagnosis Error 300 Claim Count Total Incurred $250,000, $200,000, number of cases $150,000,000 $100,000,000 total incurred 50 $50,000,000 0 Dx-related Surgical TX Treatment Tx OB-related Tx Med-related $0 N=584 high-severity PL cases asserted 1/1/02-8/31/07. Total Incurred-aggregate of expenses, reserves, and payments on open and closed cases.

13 Estimates - Diagnostic Error Rate Visual specialties Internal Medicine Med Specialties Radiology, Patholodgy: 2-5% missed findings 10-15%???? Evidence Source Opinion Standard Patients Findings 1 in 10 diagnoses are wrong Internists misdiagnosed 13% of patients with common conditions Case studies Delayed dx in 10 40% Autopsies Major unexpected findings: 10-20% Chart Review Dx error in 1 of every 20 PC patients Graber ML. The incidence of diagnostic error in medicine BMJ Qual Saf Singh et al. Frequency of diagnostic error in ambulatory care BMJ Qual Saf

14 The toll of Dx Error US 40,000 80,000 deaths/yr Your Hospital 10 deaths every year Error-related Harm 10 patients harmed every day in your clinics or ER Diagnostic Error Leape et al. JAMA 288:2405, 2002 Singh et al. BMJ Qual Safety 21: , 2012

15 IOM: It is likely that most of us will experience at least one diagnostic error in our lifetime, sometimes with devastating consequences.

16 Where do they happen? CRICO - Analysis of 4519 claims related to diagnostic error Ambulatory care clinics it s NOT just rare conditions. Dx errors are COMMON in patients with anemia, asthma, COPD

17 What Is the Cause of Diagnostic Error?

18 Error in the Diagnostic Process DIAGNOSTIC ERROR (Wrong, missed & delayed diagnosis) No Fault Causes Silent disease Too early; atypical Patient misleads us Patient doesn t f/u Inconsequential HARM

19 Diagnosis is HARD! PATIENT VARIABLES Stage of disease How it manifests How it is perceived How it is described When help is sought SYSTEM COMPLEXITY Disjointed care Communication barriers Production pressure Tight coupling Access to care & expertise PHYSICIAN VARIABLES Knowledge and experience Access to patient data, tests, consults Skill in clinical reasoning Stress, distractions, mood, time to think

20 How Many Diseases Are There? World Health Organization: ICD ICD ICD ? ICD ,420 NLM: 8000 MESH terms Growing /year

21 Error in the Diagnostic Process DIAGNOSTIC ERROR (Wrong, missed & delayed diagnosis) No Fault Causes Silent disease Too early; atypical Patient misleads us Patient doesn t f/u Inconsequential HARM

22 Root cause analysis NPSF study: 100 cases 535 root causes Graber et al. Arch Int Med 165:1493-9, 2005 BLUNT end SYSTEM Communication, coordination, training, policies, procedures SHARP end Me Patients Clinical Course Cognitive

23 Both System and Cognitive Errors 46% Etiology of Diagnostic Error No Fault Error Only 7% System Error Only 19% Cognitive Error Only 28%

24 Of all system errors (n = 215), the most common were: Communication TYPE Coordination of care Expertise available Culture of safety Supervising trainees Workload, stress, distractions Reliability of lab, X-rays Staff training, dedication, competency, compatibility EXAMPLE Critical lab abnormality lost Medical records aren t available No radiologist on nights No system to find dx errors Trainee errors on weekends Short exam: missed a key finding Small lung nodule missed on X-ray Residents mis-read chest X-ray on PACS system Normalization of deviance

25 Cognitive Errors: 320 Faulty Knowledge 3 % Faulty Data Gathering 14 % Faulty Synthesis 83 %

26 How Do Doctors and Nurses Think?

27 How Do Doctors and Nurses Think?

28 This past weekend the patient was clearing brush from his back yard, wearing shorts. He now has a very itchy rash: vesicles, linear, just where his skin was exposed. 1. Morphea 2. Chicken pox 3. Poison Ivy 4. Pemphigoid

29 System 1: Automatic, subconscious processing EXPERT HEURISTIC Recognized? Repetition Diagnosis System 2: Deliberate, conscious thought

30

31 Availability Heuristic The Benefits Fast, effortless Approximates the base rate of disease Very often correct The Drawbacks Discourages the consideration of a broad differential Our experience is limited Available does not necessarily mean correct

32 What Does it Feel Like to be Wrong?

33 Think about the letter R. Which is more common? A. R as the FIRST letter of a word? B. R as the THIRD letter of a word?

34 The Problem of Cognitive Bias 34

35 What advice did you receive to get the best score on multiple choice tests? A. Trust your intuition B. At the end of the test, go back and reconsider the questions you weren t sure about

36 Wrong to Right to Wrong to Wrong Wrong Right

37

38 Q: How do we think? A: For the most part, using our intuition = subconscious, automatic, thinking This works extremely well, but it s not perfect, and MANY diagnostic errors arise from errors in these processes. Diagnosis is too important a process to rely solely on intuition

39 Delayed Diagnosis of Sepsis Cognitive Errors Knowledge: OK? Data collection: Incomplete Synthesis: Faulty Wrong context; Premature closure System Errors Lab results not available fast enough Inadequate plan for follow-up No system to learn from errors

40 Say What s a mountain goat doing way up here in a cloud bank?

41

42 Premature closure = Satisficing = Falling in love with the first puppy (Herbert Simon)

43 Cognitive Error is EVERYWHERE Diagnosis Military decisions Business decisions Legal decisions Political decisions EVERY DAY LIFE The consequences may differ; the errors are the same

44 So where are we?

45 The Coalition to Improve Diagnosis American Board of Internal Medicine and the ABIM Foundation American Board of Medical Specialties American College of Emergency Physicians American College of Physicians American Society of Healthcare Risk Managers Consumers Advancing Patient Safety Leapfrog Group National Patient Safety Foundation National Partnership of Women and Families National Association of Pediatric Nurse Practitioners Society to Improve Diagnosis in Medicine Department of Veterans Affairs Veterans Healthcare Agency organizations as of May 2017 Advisory: AHRQ, CDC, CMS

46 Addressing Cognitive Problems Problems Solutions System 1 System 2 Faulty context Premature closure Failed heuristic Practice reflectively Consider the opposite Be comprehensive The universal antidotes: What else could this be? A differential diagnosis

47

48 VITAMIN C C & D V I T A M I N C C D ascular nfections & intoxications rauma & toxins uto-immune etabolic diopathic & iatrogenic eoplastic ongenital onversion (psychiatric) egenerative

49 CHECKLISTS Feeling cold (chills) Advanced age Psychiatric (anxiety) Hypothyroidsim Shock Sepsis Raynaud s phenomenon Anemia Malnutrition Hypoglycemia Renal failure John Ely Available at:

50 Aids for Differential Diagnosis Dxplain Isabel Derm

51 Isabel Isabelhealthcare.com

52 IMPACT OF ISABEL Studied pediatric ICU admissions who did NOT have a diagnosis on admission (n = 206). Correct diagnosis rates: Residents on their own: 89.4% Residents + Isabel: 92.5% Residents + Isabel + Attending 95% Thomas et al. International assessment of a web-based diagnostic tool in crically ill chlidren. Technol Health Care 2008; 16:

53 SECOND OPINIONS CHANGE THE DIAGNOSIS Radiology, Pathology: 2-5% Internal medicine: 10-20%

54 PHYSICIANS & APRN s - What can I do? Be thoughtful and reflective Learn why dx errors occur and how to avoid Always construct a differential diagnosis Take advantage of second opinions Use decision support resources Make the patient your partner

55 RN s - What can I do? Contribute to the diagnosis Monitor communication effectiveness Monitor for diagnostic errors: Things that don t fit; course not congruent with dx Help the patient with navigation, communication, and follow-up

56 1977 KLM Tenerife 583 people aboard 2 airplanes died when KLM Flight 4805 attempted take off on a runway that was occupied by another jet, in a fog. The pilot mistakenly believed he had received clearance to take off; the co-pilot questioned the take off but did not press the issue Crew resource management

57 GOAL 1 Facilitate more effective teamwork in the diagnostic process among health care professionals, patients, and their families

58 Teamwork

59 I love to hear a choir. I love the humanity to see the faces of real people devoting themselves to a piece of music. I like the teamwork. It makes me feel optimistic about the human race when I see them cooperating like that. Paul McCartney

60 Improving the diagnostic process is not only possible, but it also represents a moral, professional, and public health imperative. GRABER.MARK@GMAIL.COM

61 Better Together Artwork of Laura Uy