A17/B17: Addressing Diagnostic Error: Creating Reliable Systems for Diagnosis and Tracking in Primary Care Gordy Schiff, MD, Associate Director of Brigham and Women s Center for Patient Safety Research and Practice, Associate Professor of Medicine at Harvard Medical School Lindsay Hunt, MEd, Director of Systems Transformation, Harvard Medical School Center for Primary Care Dan Cohen, MD, Chief Medical Officer, Datix Ltd (UK) and Datix Inc (USA) Mark Graber, MD, Founder, Society to Improve Diagnosis in Medicine These presenters have nothing to disclose. Objectives Understand the broad range of human factors that interfere with and degrade diagnostic accuracy and timeliness. Identify patient-centered processes to enhance collaborative efforts of clinicians and patients regarding performance, systematic tracking and follow-up of appropriate screening and diagnostic testing. Identify specific changes to test to create more reliable processes at your own organizations. 1
Ryan s Story 2
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 6 3
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 Don t miss diagnoses, red flag symptoms Diagnostic pitfalls potentially useful construct 8 4
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; 5
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 12 6
Background Diagnostic errors arise from system/process insufficiencies and from human mistakes Solutions to system/process insufficiencies rely on standardization of workflow Strategies for overcoming human mistakes will require better understandings of human cognition and how to make this more reliable. Working together we hope to develop strategies to overcome diagnostic errors that you and we have encountered And we want to learn from you! IOM: Improving Diagnosis Health Care 2015 http://nas.edu/improvingdiagnosis All of Us Recommendations Practice Improvement 7
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 Diagnostic Error: RCA Framework 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 Cognitive Patients Clinical Course 8
The SaferDX Framework; Singh & Sittig, BMJ Qual Saf 2015 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 9
Cognitive Errors: 320 Faulty Knowledge 3 % Faulty Data Gathering 14 % Faulty Synthesis 83 % The Problem of Cognitive Bias 20 10
Human Factors Why they are important The processes of healthcare rely on personnel interacting with structures, technologies and with other individuals to achieve outcomes Human factors are those elements that affect each individual s ability to work within structures and to implement the processes effectively Many human factors are well characterized but others may be less apparent, yet compelling in their effects Human Factors Stuff that helps or hinders performance Psychological, physical characteristics of user Relationship between users and broad environment Workspace/noise/temperature/alarms Ergonomics: human technology/equipment interface Stressors not often appreciated Hidden factors Social pressures Economic pressures Management/admin pressures Staff - collegiality/teaming/conflicts/personalities Hunger/fatigue/task saturation/workload 11
Emergency Room Delayed Diagnosis A Story to Start 4 year-old child with fever/lassitude/urinary frequency/history of urinary tract infections Triage nurse orders lab studies per protocol/places child in non-urgent queue Child seen by ED physician two hours later Additional history of maternal sickle cell trait/polyuria Lab studies never performed/physician not alerted Child deteriorates/noted to have sweet odour to breath Dx Hgb S/C disease, diabetic ketoacidosis, pneumococcal sepsis Child nearly dies possibly due to delayed diagnosis 12
The Contributing Hidden Human Factors What the first investigation found The beatings will continue until morale improves! What a deeper dive found Dissecting Diagnostic Errors/Delays Clinicians do not plan to harm patients Well-trained professionals make mistakes every day Diagnostic errors/delays arise from insufficiencies in structures, processes and human performance Accurate/timely Diagnosis is dependent on collaboration between professionals and patients Safety Investigations should focus on structures and processes, and human factors Safety Investigations are about learning, improving safety and most of all. about improving outcomes 13
27 AIC CARES Aims 1. Continue practice transformation towards high functioning interdisciplinary teams. 2. Prevent missed and delayed diagnoses of colorectal and breast cancer, OR: Reduce the gap between positive developmental screen to completion of a referral for children ages 0 3. 3. Create new systems and processes for integration of care for patients at high risk for patient safety harms. 4. Train multi-disciplinary teams of leaders capable of spreading and facilitating spread. 14
AIC CARES Timeline 2014 2015 2016 L S 1 L S 2 Prevention of Missed and Delayed Dx: Colorectal Cancer (Adult) Developmental Delays (Pediatric) Oct Dec Feb April L S 3 L S 4 Improve Outcomes for Patients with Complex Care Needs L S 5 L S 6 June Aug Oct Dec Prevention of Missed and Delayed Dx: Breast Cancer (Adult) TBD (Pediatric) Feb April June 90-day R&D Process Institute for Healthcare Improvement 15
Table Discussion 1. What are the related diagnosis or loop closure challenges that are keeping you up at night? 2. What s working well at your organization (or others)? Where are the bright spots? 16
Report Out 1. What are you struggling with around Dx errors at your organization? 2. What s working? Where are the bright spots? Today s Objectives Understand the broad range of human factors that interfere with and degrade diagnostic accuracy and timeliness. Identify patient-centered processes to enhance collaborative efforts of clinicians and patients regarding performance, systematic tracking and follow-up of appropriate screening and diagnostic testing. Identify specific changes to test to create more reliable processes at your own organizations. 17
Wrap-up/Next Steps 18