Session #5: Delayed Diagnosis,
Misdiagnosis and Altogether
Missed Diagnosis
Speaker: Laurie Drill-Mellum
Date: Saturday, Jan. 10
Time: 11 a.m. – 12:15 p.m.
Laurie Corrine Drill-Mellum, M.D., MPH, FACEP
Laurie Drill-Mellum, M.D., MPH, is MMIC’s first chief medical officer, appointed in 2012.
Laurie practiced emergency medicine full-time at Ridgeview Medical Center in Waconia,
Minnesota, from 1991 until early 2012 when she accepted her position with MMIC.
During her tenure, she held roles as chief of the medical staff and medical director of the
emergency department. She is currently the co-medical director of Ridgeview’s hospice
program and works an occasional ER shift. She is also an instructor for the
Comprehensive Advanced Life Support program. Laurie is a Fellow and member of the
American College of Emergency Physicians. She is a member of the American Medical
Association, the Minnesota Medical Association, the Twin Cities Medical Society, and
the American and Minnesota Holistic Medical Associations.
Errors in Diagnosis 1/10/2015
Errors in Diagnosis
Analysis and Prevention Strategies
Laurie Drill-Mellum, M.D., MPH
Chief Medical Officer, V.P. of Patient Safety Solutions
Minnesota Hospital Association 2015
Winter Trustee Conference
January 10, 2015
Copyright 2014 MMIC • All rights reserved
you
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1
Errors in Diagnosis 1/10/2015
Diagnostic error in malpractice claims
#3
most frequent allegation
#1
in total cost
behind surgical treatment and medical treatment
Copyright 2014 MMIC • All rights reserved
Getting it wrong
A hospital can be rewarded through
“pay-for-performance initiatives for giving all of its
patients diagnosed with heart failure, pneumonia
and heart attack the correct, evidence-based and
prompt care …
… even if every one of the diagnoses was wrong.”
(Robert Wachter, 2010)
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2
Errors in Diagnosis 1/10/2015
Rory Staunton … undiagnosed sepsis
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Why improvement is possible just now
Better data
Better neuroscience
Better tools and systems
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3
Errors in Diagnosis 1/10/2015
Better data
Digging deeper, seeing more
• MMIC partners with
CRICO Strategies (2013)
– Harvard-based
– Leading with medical data
– Expanded patient safety
mission in 1998 to extend
beyond Harvard
– Created a national comparative
benchmarking database
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Errors in Diagnosis 1/10/2015
CRICO’s Comparative Benchmarking Database
>300,000 claims
~30% of National Practitioner Data Base
Membership
Copyright 2014 MMIC • All rights reserved
Copyrighted by and used with permission of The Risk Management Foundation of the Harvard Medical Institutions, Inc., all rights reserved.
Top major (primary) allegations
Comparative Benchmark System (CBS)
number of cases
total incurred
$900,000,000
$774 million (27%)
6,000
> $1$800,000,000
billion
w/ expenses
$700,000,000
5,000
$600,000,000
4,519 cases (20%)
4,000
$500,000,000
$400,000,000
3,000
$300,000,000
2,000
$200,000,000
1,000
CBS N=22,292 PL cases closed 1/1/08–12/31/12
www.MMICgroup.com
Pt Monitoring
Anesthesia
Safety & Security
OB
Medication
Diagnosis
Medical Tx
$100,000,000
Surgical Tx
0
INDEMNITY PAYMENTS
NUMBER OF CASES
7,000
$0
© 2014 CRICO Strategies, all rights reserved.
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Errors in Diagnosis 1/10/2015
The majority of diagnosis-related cases originate
in the ambulatory setting.
Series1
Series2
Series3
70%
60%
Outpat
ient
57%
Percent of Cases
ED
16%
Inpatient
27%
50%
40%
30%
20%
10%
0%
1
2
3
Assert Year
CBS N=4,184 PL cases asserted 1/1/2008–12/31/2012
National Landscape: Claimant Type in Diagnostic-related Cases
4
5
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Inpatient Comparison – CBS, MMIC, MN
Top major (primary) allegations
Series1
Series2
Series3
50%
PERCENT OF CASES
45%
40%
35%
Tied for
30%
3rd
in MN inpatient cases
25%
20%
15%
10%
CBS peers
MMIC
Minnesota
Asserted
www.MMICgroup.com
8
7
6
5
4
3
2
0%
1
5%
n=7,577
n=721
n=192
1/1/2010-12/31/2013
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Errors in Diagnosis 1/10/2015
Inpatient Comparison – CBS, MMIC, MN
Top major (primary) allegations
Series1
50%
12%
PERCENT OF CASES
45%
40%
Series2
Series3
10%
7%
35%
30%
25%
20%
15%
10%
CBS peers
MMIC
Minnesota
Asserted
8
7
6
5
4
3
2
0%
1
5%
n=7,577
n=721
n=192
1/1/2010-12/31/2013
ED & Outpatient Comparison – CBS, MMIC, MN
Top major (primary) allegations
Series1
Series2
Series3
35%
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#
20%
1
in MN ED & OP
15%
10%
7
6
5
4
3
2
5%
0%
CBS peers
MMIC
Minnesota
Asserted
Dx-related is
25%
1
PERCENT OF CASES
30%
n=9,616
n=1070
n=331
1/1/2010-12/31/2013
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Errors in Diagnosis 1/10/2015
VISIBLE “UNIQUE” EVENT
NOT-SO-VISIBLE-OR-UNIQUE UNDERLYING ISSUES
Failure to monitor physiological status
Failure to follow protocol
Inadequate communication
Lack of adequate assessment
Narrow diagnostic focus
Failure to ensure patient safety
Resident supervision
Failure/delay ordering diagnostic test
© 2014 CRICO Strategies,
all rights reserved.
Example: Clinical judgment
Patient assessment issues
Rely on negative findings with continued symptoms
Failure to establish differential diagnosis
Lack/inadequate history and physical
Lack/inadequate assessment – premature diagnosis
Failure to rule out abnormal finding
Failure/delay in ordering diagnostic test
Failure to respond to patient’s concerns
Patient monitoring
Patient monitoring—physiological
Patient monitoring—medication
*A case may have multiple issues identified.
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Copyright
2013 MMIC
All rights
reserved
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Strategies,
all •rights
reserved.
8
Errors in Diagnosis 1/10/2015
Where diagnostic errors occur
17
History
Exam
10%
10%
Assessment
33%
Lab and
Radiology
Testing
46%
Schiff, G. et al, 2009, Gandhi, TK, et al, 2006
Copyright 2014 MMIC • All rights reserved
Top outpatient diagnostic errors
Cancer (10:1over other causes)
Cardiac disease
Fractures & dislocations
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9
Errors in Diagnosis 1/10/2015
Most often
missed in
inpatient setting
MIs - cardiac events
Complications of care
(failure to rescue)
Infections/Sepsis
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Similar Key Factors
in both inpatient and outpatient settings
IN-PATIENT
AMBULATORY
% CASES*
% CASES*
Clinical Judgment
72%
Clinical Judgment
71%
Communication
31%
Communication
24%
Clinical Systems
19%
Behavior-related
21%
Documentation
16%
Clinical Systems
19%
Behavior-related
12%
Documentation
16%
Narrow diagnostic focus
27%
Failure / delay in ordering a test
31%
Failure / delay in obtaining consult
17%
Failure / delay in obtaining consult
19%
Communication among providers
20%
Communication among providers
10%
Communication / patient/family
3%
Communication / patient/family
9%
15%
Misinterpretation of studies
21%
© 2014 CRICO Strategies, all rights reserved.
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10
Errors in Diagnosis 1/10/2015
Findings in MMIC claims
Less than aggressive pursuit of
short-term / urgent presentations
•
•
•
•
•
•
•
Failure to respond to repeated complaints
Failure to generate a broader differential diagnosis
Failure to obtain tests
Failure to consult or refer
Misinterpretation of diagnostic studies
Lax use of “protocols” / best practices
Inattention to / normalization of co-morbidities
Copyright 2013 MMIC • All rights reserved
© 2014 CRICO Strategies, all rights reserved.
Potential solutions
Creating an integrated diagnostic community
for the (isolated) practitioner
• Video/Skype conferencing for clinical consults
• Telemedicine (remote radiology review)
Copyright
2014 MMIC
• All rights
reserved
© 2014 CRICO
Strategies,
all rights
reserved.
www.MMICgroup.com
11
Errors in Diagnosis 1/10/2015
Potential solutions
Creating an integrated diagnostic community
for the (isolated) practitioner
•
•
•
•
•
Consult resources (pools / MD Connect)
Protected “discussion sites” for ongoing dialogue
Guidelines (embedded in EMR)
CME targeted to known risk areas (cardiac, gyn)
Diagnostic tools
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© 2014 CRICO Strategies, all rights reserved.
Next steps
Creating focus on and investment in improving
the diagnostic process
• Data analysis / sharing (claims, adverse events,
patient complaints)
• Case studies (teaching abstracts)
• Educational forums: ambulatory M&M, grand rounds
• Practice collaborative (share issues, concerns,
solutions)
• Culture of Safety survey
• Physician office / practice evaluations
• Proactive peer review (trends and triggers)
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© 2014 CRICO Strategies, all rights reserved.
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Errors in Diagnosis 1/10/2015
Better neuroscience
Exploring our thinking patterns
26
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13
Errors in Diagnosis 1/10/2015
Thinking fast and slow
System 1
System 2
Intuitive
Fast
Automatic
Effortless
Implicit
Emotional
Analytical
Slower
Conscious
Effortful
Explicit
Logical
Illustration by David Plunkert
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Common cognitive biases
• Anchoring bias – locking on to a diagnosis too
early and failing to adjust to new information
• Availability bias – thinking that a similar recent
presentation is happening in the present
situation
• Confirmation bias – looking for evidence to
support a pre-conceived opinion, rather than
looking for information to prove oneself wrong
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Errors in Diagnosis 1/10/2015
More biases
• Diagnosis momentum – accepting a previous
diagnosis without sufficient skepticism
• Overconfidence bias – over-reliance on one’s
own ability, intuition, and judgment
• Premature closure – similar to “confirmation
bias” but more “jumping to a conclusion”
• Search-satisfying bias – the “eureka” moment
that stops all further thought
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And more biases
• Affective bias – when one’s emotional state
adversely affects one’s decision-making
• Representative bias – looking for prototypical
manifestations of a disease
• Framing – drawing different conclusions from
the same information, depending on how that
information is presented
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Errors in Diagnosis 1/10/2015
Cognitive debiasing strategies
• Encourage decision makers to get more
information
• Encourage metacognition (thinking about your
thinking) and reflection
• Recognize personal biases
• Maintain a healthy skepticism – question
everything – “What else could this be?”
• Involve others – group decision-making can be
smarter
• Use clinician tools and checklists
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Better tools
and systems
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Errors in Diagnosis 1/10/2015
Consider technological solutions
• Clinical decision-making support systems such
as Isabel and Visual Dx
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Consider technological solutions
• Electronic medical records with embedded
clinical guidelines
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Errors in Diagnosis 1/10/2015
Consider technological solutions
• Integration of information from sources including
clinics, hospitals, labs and imaging facilities
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Strengthen vulnerable systems
•
•
•
•
•
Patient follow-up protocols
Communication of test results
Management of patient referrals
Processes for covering physicians
Robust documentation
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Errors in Diagnosis 1/10/2015
Help your
providers thrive
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Make physician health and well-being a priority
•
•
•
•
Put it in your mission statement
Measure it
Invest in training tools
Incorporate feedback
tools in staff development
• Encourage self-care
and promote resiliency
practices
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Errors in Diagnosis 1/10/2015
Promote a collaborative culture
Do care team members
• Feel supported and support each other?
• Know how to have quality conversations with
patients and colleagues that yield the information
they need?
• Have an accurate perception of their strengths
and weaknesses?
• Know it’s okay to be less than perfect?
• Know how to keep themselves in optimal
condition for their demanding work?
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It might have made a difference for Rory
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Errors in Diagnosis 1/10/2015
Putting it all together for patients
Better data
Better neuroscience
Better tools and systems
Copyright 2014 MMIC • All rights reserved
12 solutions for health systems
1. Provide training/education
2. Use problem lists,
decision support tools and
differential diagnosis
3. Leverage EHRs
4. Ensure availability of
stat radiology reads
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Errors in Diagnosis 1/10/2015
5. Encourage patient engagement
6. Establish ways for providers to receive
feedback on their diagnoses
7. Use systems to follow up on tests and
referrals
8. Close the loop on diagnostic test results
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12 solutions for health systems
9. Monitor errors
10. Ensure that providers designate a
surrogate to review test results
11. Have senior clinicians mentor trainees
on new cases
12. Encourage teamwork with nurses
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Errors in Diagnosis 1/10/2015
References
Ghandi TK et al. Missed and delayed diagnoses
in the ambulatory setting: a study of closed
malpractice claims. Ann Intern Med. 2006
145(7):488-96.
Graber, M. Inside Medical Liability, PIAA
Publication, 2014 First Quarter:22-26.
Graber M. The incidence of diagnostic error in
medicine. BMJ Qual Safety, 2013.
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References
Leape, L, Berwick, D, Bates, D. Counting deaths
from medical errors. JAMA.2002 288(19):2405.
Schiff, GD, Hassan O, Kim, S, et al. Diagnostic
error in medicine: analysis of 583 physicianreported errors. Arch of Intern Med 2009
169(20):1881-7.
Singh H et al. Types and origins of diagnostic
errors in primary care settings. JAMA Intern Med.
2013 173(6):418-425.
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Errors in Diagnosis 1/10/2015
Laurie Drill-Mellum, M.D., MPH
952.838.6874
[email protected]
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