safe diagnosis 2
TRANSCRIPT
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Safe Diagnosis
Toward a Patient Centred NHS
Presentation to the Academy of Royal Medical Colleges atthe Royal College of Surgeons 13/9/05
Nick Green Patient Public Involvement Forum Organisation
Reducing Error and Delay
http://www.ppif.org.uk
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Why am I qualified to talk about
this?
The consulting cybernetician
Decision making under uncertainty motivatescybernetics
General Management Heuristic reduces error Error Detection and Correction
Change when policy fails
Alerting, Modelling and Real Time Audit
The Body Project: to understand and catalogueall physiological and pathophysiologicalprocesses
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Background
Lethal Medical Accidents
NPSA 840 patients died
(First Annual Report 2005)
Dr Foster estimates 40,000 died
(BMJ 2004;329:369)
Rath from US data150-200,000 died
(Dr. Rath Health Foundation 151 refs)
"Compared with the transport industry, the numberof errors causing very high levels of death is
extraordinary." Roger Taylor, research director of Dr Foster
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Deaths
In 2004 514,250 died in UK and Wales
About half in hospital (BMJ. 2004 May 22;328(7450): 12351236 )
Worst case: 1 in 5 die without diagnostic ortreatment error
Best case 19 out of 20 die without diagnosticerror
Hospital death rates are reducing by 2.6% per
year (B. Jarman, The quality of care inhospitals The Journal of the Royal College ofPhysicians of London 34,Jan/Feb 2000)
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Life expectancy is increasing
Life expectancy has increased 1 year in every 4
since 1981. 1 day every 4. Why?
Are treatments improving at this rate?
ONS Life Expectancy 2004http://www.statistics.gov.uk/CCI/nugget.asp?ID=881&Pos=1&ColRank=1&Rank=374
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Causes of Death
ONS Life Expectancy 2004
http://www.statistics.gov.uk/CCI/nugget.asp?ID=881&Pos=1&ColRank=1&Rank=374
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Concurrent Interacting Processes
Virus Disease
Musculoskeletal
Blood
Lymph
Marrow
Endocrine
Ear
The Nomencleture of Disease HMSO 8th
edition
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The schoolboy howler
Patient presents anxious may havedisease with back ground rate of 1 in 1000
Diagnostic test has 95% true positive rate
Result positive
What are my chances Doc?
In fact its 50 to 1 you are ok!
One test is not enough
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Doctor Foster
Only 276,514 errors were recorded in Englishhospitals in 2004 but the National Patient Safety
Agency (NSPA) puts the true figure at closer to900,000 (Chief Medical Officer).
Approximately 25 per cent of errors occur duringsurgery
25 per cent in diagnosis or pre-care: more than200,000 in a yearhttp://home.drfoster.co.uk/news_items/1309/The Times 13 08 04.pdf
Half of all mistakes are made during wardtreatment from inadequate nutrition to incorrectdose of medication
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The Patient Model
Gold Standard:
Is the death Certificate Correct?
Diagnose Treat Outcome
10-20,000 diseases :
14-15 yes/no unambiguous questions could define
it if correctly answered. Getting these questions
correctly answered is the skill of correct diagnosis.
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Sington and Cottrell J Clin Pathol 2002;55:499502
Medical errorreporting must take necropsy data into
account Letter: BMJ2001;323:511 47% of Death Certificates correct for hospital
deaths.
Cardiovascular deaths 28% accurate
Malignant deaths 35% over diagnosed
Rate of necropsy well below recommended 10% Necropsy is not random
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Random Necropsy
If Sington and Cottrell were random then at least50% of patients are treated for the wrongdisease.
If they are worst or hard cases then 5% of
patients are treated for the wrong disease.
Challenging Cases
Prof John Senders estimates that iatrogenicdisease affects between 5% and 50% of allpatients.
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Safety critical methods
Multiple independent teams
Agreement
Self-vetoing Proof of correctness
Background error rate critical
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Improving Diagnostic Accuracy
Assume Diagnosis 75% accurate.
One doctor .75 chance of being right
Two doctors .94 of being right
Three doctors .98. Only 1 in 50 patients will
be treated for the wrong disease.
But only if independent! New history, tests and
no prompting from patient on previous findings. Bonus for diagnosticians with novel finding?
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Removing the Error from Diagnosis
-
50,000
100,000
150,000
200,000
250,000
300,000
1 2 3 4 5 6 7 8 9 10
Number of Independent Diagnoses
Errors per
million
diagnoses
Starting with 1 in 4 diagnoses wrong with one diagnostician.
Ten independent diagnoses, if they agree, will reduce diagnostic error to 1 in a
million. Culture Change! Responsibility for error shared and better feedback
for diagnosticians from colleagues
110
49
158
617
2446
9775
3,9064
15,6253
62,5002
250,0001
Errors per millionNo of Doctors
Assume no
medical break
throughs
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Even at 95% 5 Diagnosticians are
needed to get to 1 in a million error
0
50,000
100,000
150,000
200,000
250,000
300,000
1 2 3 4 5 6 7 8 9 10
75%
80%
90%
95%
110
149
3158
13617
1642446
1103209775
61001,6003,9064
1251,0008,00015,6253
2,50010,00040,00062,5002
50,000100,000200,000250,0001
95%
error
90%
error
80%
error
75%
error
Errors per millionDiagnostic
Agreement
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How to proceed?
Consultant General Physician
Decision and Risk analysis
More detail on Death Certificates: toxicburden
Multiple blind diagnosis will need major
changes to Clinical Practice. Likely savings make it feasible.
Treatment costs halved?
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Persistent Organic Pollutants
In water, food and homes
In cadavers routine at random postmortem
Synergystic toxicity: cocktail effect ofsub-toxic exposure.
Advance Directives
Religious objectors may reconsider whenthey realise they will get poorer qualitytreatment.
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Treatment errors
Wrong treatment
Side effects of right treatment
Right treatment wrongly given, incorrect
dosages- surprisingly common
CfH (NPfIT): complete real time audit of allinterventions.
Data mine of outcomes will quickly rivalPharmaceutical companies if recordingoutcomes mandatory
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Body Knowledge Mining
When CfH established
Shift NHS staff into fundamental research
2.3 in-patients per hospital doctor
1.8 nurses per patient
2 support staff per in-patient
Raise status
Elite in data capture
Majority in checking and cataloguing
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Decision
Development
Audit
Operation
Regulation
Process
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Interactions of Actors Axioms
Context
Perspective
Responsible
Respectable
Amity Agreement
Agreement-to-disagree (ATD)
Purpose
Unity not uniformity
Faith Beginnings and Ends (CT)
Eternally interacting (IA)
Similarity and Difference
Adaptation
Evolution
Generation
Kinetic (IA) Kinematic (CT)
Conservation of MeaningfulInformation Transfer bothPermissive (Ap) andImperative Application (Im)
Informational openness andOrganisational closure.
Void and Not-Void
Coherence: the product of a process
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Controlling the View of the Patient
Care Record
Independent multiple diagnoses requires
Same view of old history up to the new
incident
No view of history and tests by
competing diagnosticians
Further diagnostic encounters till riskreduced to some agreed standard level
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We need a Tricorder!
Nick Green FCybS 13/9/05 Safe Diagnosis
Contact: 020 7916 0285 [email protected]
mailto:[email protected]:[email protected]:[email protected] -
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First PPIFO Conference for 2006
Speakers who have agreed to come or expressed interest include:
Alexander Harris (Malpractice Solicitors)
Dr Vernon Coleman (Decisions, Evidence and error)
Dr Barrie Cottrell (Inaccuracy of Death Certificates)
Dr Richard Fitton (NHS Connecting for Health) Dr Phil Hammond (Medical Culture)
Prof Lewis Wolpert FRS (Biology and Safer Medicine)
Sir Brian Jarman has suggested we approach the Chief MedicalOfficer on his plans for patient Safety and we think a senior DoHexecutive should be approached to talk about remedies for non-compliance with hand washing, cleaning contracts, queues, nursingstandards etc.
We are looking for co-sponsors for what we would like to be a freeevent. PPIFO ( http://www.ppifo.org.uk) is not grant aided.
http://www.ppifo.org.uk/http://www.ppifo.org.uk/ -
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The Pendulum" by Baker and Blackburn. Huygens 1665 saw clockpendulums sy nchron ize hanging on the same wal l .
A class ical example of the weak dr iving, stro ng co upl ing case.
Weak d r iv ing w i th s t rong coupl ing
produces synchronisation or coherence-
and narrow stat ist ical var iance onoutcomes.
St rong dr iv ing w i th weak coup l ing
produces unsynchronisat ion or
decoherence- and w ide var iance on
outcomes.