cognitive errors: how great clinicians reach wrong … errors - trauma...modeled on:croskerry p....
TRANSCRIPT
JAMIE FOX, MDASSOC PROFESSOR
DEPT OF PEDIATRICS
DIV HOSP/EMERG MED
Cognitive Errors:How Great Clinicians Reach
Wrong Conclusions
DAVID GORDON, MDASSOC PROFESSOR
DEPT OF SURGERY
DIV EMERG MED
March 12th, 2015
Overview of Dx Errors
Dual-Process Theory
Prevention Strategies
Cognitive Biases
Medicine Trauma
Mark Graber, MD
Missed, Delayed, or Wrong Diagnosis
Hardeep Singh, MD
Missed opportunities to make a timely or correct diagnosis
James Reason, PhD
The failure of a planned action to achieve its desired goal
What is Diagnostic Error?
122,577 patients admitted to six trauma centers
Significant preventable errors in 4% of patients
5.9% preventable or potentially preventable trauma deaths
1,295 total deaths
Davis et al., Journal of Trauma, 1992
An Analysis of Errors Causing Morbidity and Mortality in a Trauma: A Guide for Quality Improvement
Phases of Care
Resus
53%
OR
26%
CC
21%
CC
50%
Resus
36%
OR
14%
Errors Preventable Deaths
Failure to appropriately evaluate abdomenMost common
Errors in neurologic resuscitation 33% resuscitative and 12% overall preventable death
Critical Careunrecognized intra-abdominal sepsis, ventilator/pulmonary management, head injury management, hemodynamic monitoring failures
Patterns of Errors Contributing to Trauma MortalityLessons Learned from 2594 Deaths
1996-200444, 401 trauma patient admissions 5.8 % deaths2.5% deaths had contributing errors
Gruen et al., Annals of Surgery, 2006
Major Patterns of Error Contributing to Mortality
Hemorrhage Control
Abdomen/Pelvic (16%)
Intrathoracic (9%)
Airway management (16%)
Inappropriate management of unstable patient (14%)
Lengthy initial operative procedure (8%)
Procedure complication (12%)
Inadequate prophylaxis (11%)
Missed or delayed diagnosis (11%)
Overresuscitation with fluids (5%)
Overview of Dx Errors
How common is diagnostic error?
DiagnosticError
Error-relatedHarm
Up to 80,000 deaths/year 10 deaths/year
1/1000 outpt encounters 1 diagnostic harm/day
US Your Hospital
Adapted from Dr. Mark Graber’s MD, FACP webinar on 12/3/13: “Preventing Diagnostic Error: Where do I start?” Sponsored by National Patient Safety Foundation
1/20 adult outpt12million adults/yr
Graber M et al. Arch Int Med. 2005;1493.
Graber M et al. Arch Int Med. 2005;1493.
0
20
40
60
80
100
120
140
160
FaultyKnowledge
Faulty DataGathering
FaultySynthesis:
Verification
FaultySynthesis:
InfoProcessing
Cognitive Errors
Overview of Dx Errors
Dual-Process Theory
Dual-Process Reasoning
Deliberate
ConsciousUnconscious
Rapid
METACOGNITI
ON
INTUITION
System 2Analytical
System 1Non-analytical
Quirk M. Intuition and Metacognition inMedical Education: Keys to DevelopingExpertise. 2006.
System 1: Intuition
NON-ANALYTIC
Relies heavily on EXPERIENCE
PatternRecognition
FAST
“Thinking without thinking” LOW
cognitive load
System 2: Metacognition
ANALYTIC
Deductive reasoning
Logical
SLOW
“Thinking about one’s own thinking”
HIGHcognitive load
System 1: Intuition
PITFALLS
Strongly influenced by
ambient conditions
Atypical presentations
Pattern mistaken for something else
System 2: Metacognition
PITFALL
SLOWIMPRACTICAL
Croskerry P. Acad Med. 2009;84:1022-1028.
DUAL PROCESS THEORY
Overview of Dx Errors
Dual-Process Theory
Cognitive Biases
Cognitive Biases
Modeled on:Croskerry P. Achieving quality in clinical decision making: cognitive strategies and detection of bias. Acad Emerg Med. 2002 Nov;9(11):1184-204.and Lucey C, Winiger D, Shim R. “Towards a More Effective Morbidity and Mortality Conference” APDIM Spring Meeting, 2004
AnchoringTendency to lock onto initial
impressions or pieces of information early in the decision-making process. Once an anchor is set, it can be difficult to move away from and new information
is interpreted around it
CourthouseDaiquiri
“Uncooperative”
Cognitive Biases
Modeled on:Croskerry P. Achieving quality in clinical decision making: cognitive strategies and detection of bias. Acad Emerg Med. 2002 Nov;9(11):1184-204.and Lucey C, Winiger D, Shim R. “Towards a More Effective Morbidity and Mortality Conference” APDIM Spring Meeting, 2004
ConfirmationTendency to look for and
weight confirming evidence to support a diagnosis
rather than evidence that refutes it
Attempted to hit nurse“Leave me alone”
Cognitive Biases
Modeled on:Croskerry P. Achieving quality in clinical decision making: cognitive strategies and detection of bias. Acad Emerg Med. 2002 Nov;9(11):1184-204.and Lucey C, Winiger D, Shim R. “Towards a More Effective Morbidity and Mortality Conference” APDIM Spring Meeting, 2004
Premature closureTendency to shut down the
decision-making process prematurely, accepting a
diagnosis before it has been fully verified
Vomiting and Uncooperative d/t
alcohol consumption
Cognitive Biases
Modeled on:Croskerry P. Achieving quality in clinical decision making: cognitive strategies and detection of bias. Acad Emerg Med. 2002 Nov;9(11):1184-204.and Lucey C, Winiger D, Shim R. “Towards a More Effective Morbidity and Mortality Conference” APDIM Spring Meeting, 2004
Diagnosis momentumOnce diagnostic labels are attached to patients they
tend to stick
He’s drunk
Cognitive Biases
Modeled on:Croskerry P. Achieving quality in clinical decision making: cognitive strategies and detection of bias. Acad Emerg Med. 2002 Nov;9(11):1184-204.and Lucey C, Winiger D, Shim R. “Towards a More Effective Morbidity and Mortality Conference” APDIM Spring Meeting, 2004
Availability HeuristicJudge things as being more
likely, or frequently occurring, if they more readily come to mind
Alcohol as opposed to head bleed as cause of
vomiting
Cognitive Biases
Modeled on:Croskerry P. Achieving quality in clinical decision making: cognitive strategies and detection of bias. Acad Emerg Med. 2002 Nov;9(11):1184-204.and Lucey C, Winiger D, Shim R. “Towards a More Effective Morbidity and Mortality Conference” APDIM Spring Meeting, 2004
Gambler’s fallacyThe belief that if a coin is
tossed ten times and is heads each time, the 11th
toss has a greater chance of being tails
“We can’t have 3 kids w/ appy in 1 shift”
Cognitive Bias
Overattachment
Alternative/
2nd Diagnosis
Inherited
Thinking
Prevalence/
Estimation
Patient
Context
Physician
Attributes
Campbell SG, Croskerry P, and Bond WF. Acad Emerg Med. 2007; 14:743-749.
CATEGORIES
Overview of Dx Errors
Dual-Process Theory
Prevention Strategies
Cognitive Biases
CHECKLISTS/PROTOCOLS
Gruen et al., Annals of Surgery, 2006
Cognitive Debiasing Strategies
Mental strategies to avoid cognitive error
Forced Thinking
THE DIAGNOSTIC TIME OUT
Forced Thinking
What else could it be?
Is there anything that doesn’t fit?
Is it possible that I have more than one problem?
• Adequacy• Are all the patient's findings
(abnormal or normal) accounted for by the diagnostic hypothesis?
Have I explained all the patient’s findings?
• Coherency• Is the diagnostic hypothesis
pathophysiologically consistent with all the clinical findings?
Is there a non-fit?
Diagnostic VerificationCriteria of Validity
Life ThreatsAdequacyConsistency/CoherencyElse (What else could it be?)
Second Problem
Unexplained Symptom(s)
Return visit
At-risk patient population
Critical condition
End of shift
When should we take a time out?
Milestones
RAPID SEQUENCE
INTUBATION FIBRINOLYTICFOR ACUTE MI
TX TIMES FOR INVASIVE
INFECTIONS
“NOT YETDIAGNOSED”
Admission Tags
CHEST PAIN – NYD
Not YetDiagnosed SHORTNESS OF
BREATH – TPD
Trying to Prevent Death
VOMITING – PD
Parental Distress
FEEDBACK LOOP
“Closing the Loop”
Patient
ED
Night Float
Team
Epidemiology
Classification
FUTUREDIRECTIONS
Challenges
Selected References
1. Berenson RA et al. “Placing Diagnosis Errors on the Policy Agenda.” 2014. http://www.urban.org/UploadedPDF/413104-Placing-Diagnosis-Errors-on-the-Policy-Agenda.pdf (Accessed July 29, 2014)
2. Berner ES and ML Graber. Overconfidence as a cause of diagnostic error in medicine. Am J Med. 2008;121:S2-S23.
3. Crandall B and RL Wears. Expanding Perspectives on Misdiagnosis. Am J Med. 2008;121:S30-33.
4. Graber ML et al. Diagnostic Error in Internal Medicine. Arch Int Med. 2005;165:1493.
5. Graber ML. Taking steps towards a safer future: measures to promote timely and accurate medical diagnosis. Am J Med. 2008;121:S43-46.
6. Schiff GD. Minimizing Diagnostic Error: The Importance of Follow-up and Feedback. Am J Med. 2008;121:S38-42.
7. Davis JW et al. An Analysis of Errors Causing Morbidity and Mortality in a Trauma System: A Guide for Quality Improvement. J Trauma 1992;32:660-666.
8. Gruen RL et al. Patterns of Errors Contributing to Trauma Mortality. Lessons Learned From 2594 Deaths. Ann Surg. 2006;244:371-380.