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1/13/2016
1
© 2015 NORCAL Mutual Insurance Company
JANUARY 23, 2016TEXAS OSTEOPATHIC MEDICAL ASSOCIATION
DALLAS, TX
Presented by:BRADFORD S. DUNKIN, MHA
MARY-LYNN RYANRISK MANAGEMENT SPECIALISTS
Diagnostic Errors:A Risk Management Perspective
© 2015 NORCAL Mutual Insurance Company
Faculty and Planners
Faculty► Bradford S. Dunkin, MHA
Sr. Risk Management Specialist
► Mary‐Lynn RyanRisk Management Specialist
Planners► Jo Townson
CME Manager/NORCAL
The faculty and planners of this activity have no relevant financial relationships to disclose.
© 2015 NORCAL Mutual Insurance Company
DISCLAIMER
The information contained herein and presented by the speakers is based upon sources believed to be accurate at the time they were referenced.
The speaker is not engaged in rendering legal or professional services other than risk management. If legal advice is required, the services of an attorney should be sought.
This document was designed for discussion purposes only and is not intended to present detailed information on our analysis and findings. It is incomplete and not intended to be used without the accompanying oral presentation.
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© 2015 NORCAL Mutual Insurance Company
Pre‐test questions
► 1: According to PIAA data from 2009‐2013, what type of malpractice claim resulted in the highest average indemnity payment?
► 2: Diagnostic errors are caused by:
A. Miscommunication
B. Breakdowns in follow up processes and care coordination
C. Errors in analytical thinking
D. Errors in intuitive reasoning
E. All of the above
© 2015 NORCAL Mutual Insurance Company
Pre‐test questions
► 3: Availability bias could result in which diagnosis error scenario:
A. Misdiagnosing a teenaged patient with influenza during flu season, when she had classic signs of bacterial meningitis (A: Availability bias)
B. Failing to diagnose cauda equina syndrome in a chronic back pain patient who kept returning to the ED with worsening back pain and saddle anesthesia. (A: Anchoring bias)
C. Failing to identify a scaphoid fracture after an ulnar fracture had been identified on the x‐ray of a car accident victim's arm. (A: satisfaction of search)
© 2015 NORCAL Mutual Insurance Company
Pre‐test questions
► 4. Research on the cognitive process of diagnosis indicates:
A. Physicians can access their memories for an almost unlimited set of diagnostic patterns.
B. There are steps physicians can take to reduce their diagnostic biases.
C. Physicians should try to decide on a patient’s diagnosis early in the assessment and then look specifically for signs and symptoms that support the diagnosis.
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© 2015 NORCAL Mutual Insurance Company
Learning Objectives
By reviewing the key risk issues related to diagnostic error, this presentation will support your ability to:
► Identify risk management issues that contribute to diagnostic errors
► Evaluate your own practice risk exposures
►Apply risk management best practices to reduce the potential for diagnostic errors
© 2015 NORCAL Mutual Insurance Company
What is 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.”
*Improving Diagnosis in Healthcare. Quality Chasm Series. Committee on Diagnostic Error in Healthcare. Erin P. Balogh, Bryan T. Miller, and John R. Ball, Editors. Board on Healthcare Services. Institutes of Medicine. September 2015.
© 2015 NORCAL Mutual Insurance Company
Diagnostic Error
► 5% of U.S. adults who seek outpatient care
► 10% of patient deaths attributed to dx error
► 6% to 17% of adverse events in hospitals
*Improving Diagnosis in Healthcare. Quality Chasm Series. Committee on Diagnostic Error in Healthcare. Erin P. Balogh, Bryan T. Miller, and John R. Ball, Editors. Board on Healthcare Services. Institutes of Medicine. September 2015.
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© 2015 NORCAL Mutual Insurance Company
Diagnostic Error
A frequent and expensive medical malpractice allegation.
► Failure to diagnose and incorrect diagnosis
►Average indemnity = $394,999*
► Paid‐to‐close ratio = 32.5%*
Compared to 26% for all claims
*PIAA Closed Claim Comparative, 2014 Edition. January 1, 2004 –December 31, 2013
© 2015 NORCAL Mutual Insurance Company
Diagnostic Errors
• System Errors
• Cognitive Errors
© 2015 NORCAL Mutual Insurance Company
System Errors
►Miscommunication
► Breakdown in Follow Up Processes
► Inadequate Supervision of Staff
► Inadequate Coordination of Care
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© 2015 NORCAL Mutual Insurance Company
DISSECTING MEDICAL COGNITION
Intuitive Reasoning
Analytical Reasoning
© 2015 NORCAL Mutual Insurance Company
Intuitive Thinking
► Compare information
Prior disease patterns
► Reflexive
Multi‐channeled
Efficient
© 2015 NORCAL Mutual Insurance Company
Analytical Thinking
► Thoughtful
Consider potential diagnoses
Hypothesis testing
► Takes time
Need to collect and weigh data
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© 2015 NORCAL Mutual Insurance Company
Integrating Intuitive and Analytical Thinking
► Benefits
► Limitations
► Biases
© 2015 NORCAL Mutual Insurance Company
Common Biases
•Anchoring/Premature Closing
•Availability
•Emotional
•Representative Restraint
•Satisfaction of Search
© 2015 NORCAL Mutual Insurance Company
ANALYSIS OF DIAGNOSTIC ERROR CLAIMS
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© 2015 NORCAL Mutual Insurance Company
0 100 200 300 400 500 600 700 800 900
Medicine
Radiology
Surgery
Pediatrics/Neonatology
Pathology
Obstetrics/Gynecology
Physician Extenders
Emergency Medicine
Other
NUMBER OF CLAIMS
Specialties Involved in Diagnostic Error Claims
NORCAL Companies Claims Data 1/1/2010 ‐ 12/31/2014
© 2015 NORCAL Mutual Insurance Company
Anchoring/Premature Closure Bias
Settling on a diagnosis early in the work‐up and discounting data
that do not fit.
© 2015 NORCAL Mutual Insurance Company
Availability Bias
Focusing on the most readily available diagnosis, even if all of
the symptoms don’t fit.
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© 2015 NORCAL Mutual Insurance Company
Emotional Bias
Diagnostic thinking influenced by the physician’s attitude about a
particular patient.
© 2015 NORCAL Mutual Insurance Company
Representative Restraint Bias
Looking only for typical manifestations of an existing
illness.
© 2015 NORCAL Mutual Insurance Company
Satisfaction of Search Bias
Stopping the search for a definitive diagnosis after finding one
explanation for the symptoms without considering comorbidities.
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© 2015 NORCAL Mutual Insurance Company
Risk Management Recommendations
System and Cognitive Errors
Intuitive and Analytical Thinking
Differential Diagnosis
Consider Alternatives
© 2015 NORCAL Mutual Insurance Company
Risk Management Recommendations
Be Aware of Biases
Practice Time Outs
Reapproach
Utilize Clinical Guidelines
© 2015 NORCAL Mutual Insurance Company
DIAGNOSTIC ERROR CLAIMSAGAINST MEDICINE
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© 2015 NORCAL Mutual Insurance Company
Medicine / Medical Subspecialties
►Family Practice
►General Practice
► Internal Medicine
►All non‐surgical subspecialties
Allergy
Cardiology
Dermatology
Endocrinology
Et cetera
© 2015 NORCAL Mutual Insurance Company
Top Five Associated Issues in Medicine Specialty Diagnostic Error Claims
NORCAL Companies Claims Data 1/1/2010 ‐ 12/31/2014
Top Five Associated Issues –
Diagnostic Error Claims Against Medicine Specialties % of claims
1. Problems with history/exam/work‐up 35%
2. Failure to follow up 13%
3. Communication problems between HC providers 11%
4. Comorbid Issues 8%
5. X‐ray error 6%
5. Problems with records 6%
© 2015 NORCAL Mutual Insurance Company
Incident Location – Medicine Specialty Claims
Practitioner's Office53%
Hospital35%
Nursing Home4%
Emergicenter3%
Hospital Outpatient Facility2%
Other3%
NORCAL Companies Claims Data 1/1/2010 ‐ 12/31/2014
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© 2015 NORCAL Mutual Insurance Company
Top Ten Conditions in Diagnostic Error Claims Against Medical Specialties
NORCAL Companies Claims Data 1/1/2010 ‐ 12/31/2014
0
50
100
150
200
250
© 2015 NORCAL Mutual Insurance Company
Case Study #1 – Breast Cancer
►40 year old female seen by PCP
Complaints of pain, swelling, tenderness in left breast
►Mammogram – inflammatory process, “no sign of cancer”
Antibiotics prescribed
►Pt. returned in one month
Continued complaints – same symptoms
Diagnosis – mastitis
Ordered a new antibiotic
© 2015 NORCAL Mutual Insurance Company
Case Study #1 – Breast Cancer
►Pt. returned five weeks later
Diagnosis ‐ possible fat necrosis and costochondritis
Told to return in six months
►Eight months later – seen by gynecologist for worsening symptoms
Mammogram – suspicious for carcinoma
Confirmed by biopsy
►Patient underwent left mastectomy
7 of 12 positive lymph nodes
Patient died from metastatic disease
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© 2015 NORCAL Mutual Insurance Company
Expert Reviews and Biases
• Radiologist
• PCPExpert
Reviewers
• Anchoring
• ContextDiagnostic
Error
© 2015 NORCAL Mutual Insurance Company
Risk Management Recommendations
Bias Awareness
Review Clinical Data
Pursue Ultimate Dx
Obtain Second Opinions
© 2015 NORCAL Mutual Insurance Company
DIAGNOSTIC ERROR CLAIMSAGAINST RADIOLOGY
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© 2015 NORCAL Mutual Insurance Company
Radiologists’ Role in Diagnosis
►Often do not have direct patient contact
►Need to discern:
Normal variants
Pathological lesions
Artifacts
© 2015 NORCAL Mutual Insurance Company
Incident Location – Radiology Claims
NORCAL Companies Claims Data 1/1/2010 ‐ 12/31/2014
► 92% of all claims against radiologists occur in the Radiology Department
24% occur in free‐standing radiology centers
►Where else do Radiology claims occur:
Emergency Departments – 4%
Physician’s office – 2%
Patient’s hospital rooms – less than 1%
© 2015 NORCAL Mutual Insurance Company
Top Five Procedures Involved in Radiology Diagnostic Error Claims
NORCAL Companies Claims Data 1/1/2010 ‐ 12/31/2014
Top Five Procedures –
Diagnostic Error Claims Against Radiologists % of claims
1. X‐rays 36%
2. CT Scans 29%
3. MRIs 11%
4. Mammography 9%
5. Ultrasound 9%
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© 2015 NORCAL Mutual Insurance Company
Top Ten Conditions in Diagnostic Error Claims Against Radiologists
NORCAL Companies Claims Data 1/1/2010 ‐ 12/31/2014
0102030405060708090
100
© 2015 NORCAL Mutual Insurance Company
Case Study #2 – Lung Cancer
► 66 year old female
► Was in a motor vehicle accident
► Ordered: Spine, shoulder and chest x‐rays
► All studies interpreted as negative by ER physician
►Patient discharged
Dx: Left shoulder strain
►Films read by Radiologist next day
Noted variation but determined to be within normal limits
© 2015 NORCAL Mutual Insurance Company
Case Study #2 – Lung Cancer
► Two years later Patient presented to PCP
Chief Complaint: Left arm pain and SOB
►Dx: Stage IV adenocarcinoma of lung
Metastasis to the brain
►Patient underwent radiation treatment and chemo
►Died 18 months after dx
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© 2015 NORCAL Mutual Insurance Company
Expert Reviews and Biases
• Radiologist
• HospitalExpert
Reviewers
• Systems Error
• DelayDiagnostic
Error
© 2015 NORCAL Mutual Insurance Company
Risk Management Recommendations ‐Radiology
Human Error Awareness
Continuing Education
Review/Comparison
Look/Judge Lesions
© 2015 NORCAL Mutual Insurance Company
Risk Management Recommendations ‐Radiology
Display Resolution
Second Opinions
Further Studies
Positive Findings
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© 2015 NORCAL Mutual Insurance Company
DIAGNOSTIC ERROR CLAIMSAGAINST SURGICAL SPECIALTIES
© 2015 NORCAL Mutual Insurance Company
Surgery / Surgical Subspecialties
►General Surgery
►Cardiothoracic surgery
►Colorectal surgery
►Orthopedic surgery
►Et cetera
© 2015 NORCAL Mutual Insurance Company
Top Five Associated Issues in Surgical Specialty Diagnostic Error Claims
NORCAL Companies Claims Data 1/1/2010 ‐ 12/31/2014
Top Five Associated Issues –
Diagnostic Error Claims Against Surgical Specialties % of claims
1. Problems with history/exam/work‐up 32%
2. Communication problems between HC providers 12%
3. Unnecessary treatment 9%
4. X‐ray error 9%
5. Failure to follow up 8%
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© 2015 NORCAL Mutual Insurance Company
Incident Location – Surgical Specialty Claims
NORCAL Companies Claims Data 1/1/2010 ‐ 12/31/2014
Hospital45%
Practitioner's Office46%
Hospital Outpatient Facility5%
Surgicenter2%
Other2%
© 2015 NORCAL Mutual Insurance Company
Most Prevalent Care Rendered in Surgical Diagnostic Error Claims
NORCAL Companies Claims Data 1/1/2010 ‐ 12/31/2014
Most Prevalent Care Rendered–
Diagnostic Error Claims Against Surgical Specialties % of claims
1. Interview and Evaluation 38%
2. Consultation 23%
3. Eye Examination 9%
© 2015 NORCAL Mutual Insurance Company
Top Thirteen Conditions in Diagnostic Error Claims Against Surgeons
NORCAL Companies Claims Data 1/1/2010 ‐ 12/31/2014
0
10
20
30
40
50
60
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© 2015 NORCAL Mutual Insurance Company
Case Study #3 – Undiagnosed Fracture
► 17 year old female
► Presented to ER with CC: Injured right ankle
►X‐Ray read:
Widening of medial ankle mortise
Soft tissue swelling
Ligament disruption
► Pt splinted
► Referred to Orthopedic Surgeon
© 2015 NORCAL Mutual Insurance Company
Case Study #3 – Undiagnosed Fracture
► Orthopedic Surgeon dxd sprained right ankle
►Pt placed in walking cast
Weight bearing as tolerated
Return in one month
►At one month visit:
Cast removed
Replaced by brace
► Pain persisted an additional two months
► Second opinion from another orthopedic surgeon
© 2015 NORCAL Mutual Insurance Company
Case Study #3 – Undiagnosed Fracture
►2nd Orthopedic Surgeon dxd:
Fracture separation of right ankle
Healing fracture of the proximal fibula
► Pt underwent ankle reconstruction
►Pt continues to have pain, weakness and tingling in her right leg
Walks with an abnormal gait
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© 2015 NORCAL Mutual Insurance Company
Expert Reviews and Biases
• Additional x‐rays
• Non‐weight bearingExpert
Reviewers
• Failure to diagnose
• Failure to properly treatDiagnostic
Error
© 2015 NORCAL Mutual Insurance Company
Risk Management Recommendations –Surgical Specialties
Be Aware of Biases
Establish Differential List
Follow Up System
Document Thoroughly
© 2015 NORCAL Mutual Insurance Company
Risk Management Recommendations –Surgical Specialties
Effective Handoffs
Coordinate Referrals
Seek Additional Evaluation
Discharge Instructions
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© 2015 NORCAL Mutual Insurance Company
RISK MANAGEMENT RECOMMENDATIONS TO IMPROVE CLINICAL REASONING, REDUCE ERRORS AND FOSTER DIAGNOSTIC ACCURACY
© 2015 NORCAL Mutual Insurance Company
IOM Goals for Improvement
► Facilitate more effective teamwork
► Enhance education and training
► Ensure health IT supports the process
► Develop approaches to collect information on diagnostic error and near misses
© 2015 NORCAL Mutual Insurance Company
IOM Goals for Improvement
►Establish a culture that supports improvement
►Develop a system that facilitates improvement
►Design care delivery and payment environments that supports the diagnostic process
►Provide dedicated research funding
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© 2015 NORCAL Mutual Insurance Company
Risk Management Recommendations
Diagnostic Time‐Outs
Seek Additional Information
Patient Education
Utilize Clinical Guidelines
© 2015 NORCAL Mutual Insurance Company
Risk Management Recommendations
Seek Diagnostic Error Rates
Consider Checklists
Use EHR Tools
Evaluate Personal Stresses
© 2015 NORCAL Mutual Insurance Company
Risk Management Recommendations
Consider Ongoing Symptoms
Consider Limits of Studies
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© 2015 NORCAL Mutual Insurance Company
Address System Errors
Address Cognitive Errors
Mitigate Biases
In Summary
© 2015 NORCAL Mutual Insurance Company
Post‐test questions
► 1: According to PIAA data from 2009‐2013, what type of malpractice claim resulted in the highest average indemnity payment?
► 2: Diagnostic errors are caused by:
A. Miscommunication
B. Breakdowns in follow up processes and care coordination
C. Errors in analytical thinking
D. Errors in intuitive reasoning
E. All of the above
© 2015 NORCAL Mutual Insurance Company
Post‐test questions
► 3: Availability bias could result in which diagnosis error scenario:
A. Misdiagnosing a teenaged patient with influenza during flu season, when she had classic signs of bacterial meningitis (A: Availability bias)
B. Failing to diagnose cauda equina syndrome in a chronic back pain patient who kept returning to the ED with worsening back pain and saddle anesthesia. (A: Anchoring bias)
C. Failing to identify a scaphoid fracture after an ulnar fracture had been identified on the x‐ray of a car accident victim's arm. (A: satisfaction of search)
1/13/2016
23
© 2015 NORCAL Mutual Insurance Company
Post‐test questions
► 4. Research on the cognitive process of diagnosis indicates:
A. Physicians can access their memories for an almost unlimited set of diagnostic patterns.
B. There are steps physicians can take to reduce their diagnostic biases.
C. Physicians should try to decide on a patient’s diagnosis early in the assessment and then look specifically for signs and symptoms that support the diagnosis.
© 2015 NORCAL Mutual Insurance Company
Answers:
► 1: Error in diagnosis
► 2: E: All of the above
► 3: A is an example of availability bias, B is an example of availability bias and C is an example of satisfaction of search.
© 2015 NORCAL Mutual Insurance Company
Answers:
► 4: B. Researchers who have investigated ways diagnostic decisions are made have found that, in order to make diagnoses, physicians compare information from each presenting patient with disease patterns they have memorized. However, researchers have also found that because clinicians can hold only a limited set of considerations in mind at any given moment, they must make continuing decisions about what is important, which can bias their decision making. Learning about various types of common biases, such as “premature closure” (coming to a diagnostic decision very early in the assessment and then disregarding signs and symptoms that don’t match that diagnosis) can help physicians avoid being erroneously influenced by them. The confines of human thought make it impossible to completely eliminate all errors in diagnosis.
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© 2015 NORCAL Mutual Insurance Company
Q & A
© 2015 NORCAL Mutual Insurance Company
Bradford S. Dunkin, MHASr. Risk Management Specialist
NORCAL Mutual800‐652‐1051, ext. 1580
bdunkin@norcal‐group.com
Mary‐Lynn RyanRisk Management Specialist
NORCAL Mutual800‐652‐1051, ext. 2045mryan@norcal‐group.com
CONTACT INFORMATION