Setting clinical risk management standards since 1913.

PROTECTORVolume 95 n Number 2 n Summer 2014

2 Diagnostic Errors: A Closer Look at a Persistent Risk

6 Clinical Judgment: Let’s Think About Thinking

14 What We Have Here Is a Failure to Communicate(and Strategies to Prevent Communication Failures)

24 Contributing Factor Potpourri: How Other Issues Play a Role in Diagnostic Errors

Protector Continuing Education Program Medical Protective is pleased to offer a free resource for Continuing Education (CE) hours for our insureds. Protector is published three times each year. In order to obtain 1 hour of free CE, you must read the most recent Protector and then complete the applicable online test – which can be accessed by logging on with your username and password at www.medpro.com or visiting http://www.medpro.com/protector-ce.

Allow sufficient time to complete the test in one sitting, as information that is not submitted cannot be saved. Upon submission of a test, you will immediately receive a pass/fail notification. If you pass with a minimum score of 80 percent, you will also receive a certificate that you should retain in your CE file. If you fail, you cannot retake that particular test. Each test will be available for approximately 4 months, until the next issue of Protector is published. Osteopathic physicians, nonphysician doctors, and advanced practice healthcare professionals can submit certificates to their professional associations for review.

If you pass two tests within 1 year, you also may be eligible to earn a 1-year risk management premium credit, which will be applied automatically at your next policy renewal.*

This journal-based Continuing Education activity was developed by Medical Protective without commercial support. Continuing Education planners, content developers, editors, committee members, and Medical Protective Clinical Risk Management staff report that they have no relevant financial relationships with any commercial interests.

* LIMITATIONS: Every effort has been made to ensure that Protector content is applicable to the risk management learning needs of all healthcare professionals. Approval by ACCME or AGD does not imply acceptance by any other accrediting body. It is the healthcare professional’s responsibility to ensure that courses are accepted by their respective licensing boards or accrediting bodies. Premium credit eligibility and amount are subject to business and regulatory approvals and may vary by policy type. Due to state filing restrictions, the premium credit associated with the Protector Online Continuing Education test is not available for physicians in Alaska; however, insureds in this state are still eligible for the free CE hours. Doctors who are less than 18 months into receiving a risk management premium credit are welcome to complete the Protector test for CE hours, but a further premium credit will not be earned. Doctors who are 18 months or more into receiving a risk management premium credit can take the Protector test to earn premium credit toward a future renewal. Completion of a risk management course does not imply or guarantee renewal.

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Dear Healthcare Provider:

The last few editions of Protector have examined emerging healthcare risks related to evolving technologies and new models of care delivery. For this edition, we’ll move our focus to diagnostic errors — a long-standing risk issue that has remained persistent throughout the years.

The diagnostic process in healthcare is paramount, as it forms the basis for subsequent patient care and outcomes. Thus, errors and mistakes that occur during diagnosis can have detrimental consequences for both patients and providers.

From a malpractice standpoint, diagnostic errors are concerning both in terms of frequency of claims and average indemnity payments. Using sophisticated data analysis, Medical Protective is able to deconstruct diagnosis-related claims and closely evaluate their root causes and contributing factors. This edition of Protector is a product of that meticulous analysis, and each article focuses on one or more significant factors that contribute to diagnostic errors. By reading the articles in this edition, you should be able to:

n Describe the ways in which diagnostic errors can potentially contribute to malpractice allegations;

n Explain several cognitive biases that can lead to flaws in clinical reasoning and decision-making;

n Identify several essential elements of a comprehensive communication policy; and

n Cite examples of how documentation issues, clinical system failures, and behavioral problems can contribute to diagnostic errors.

As a reminder, Medical Protective is accredited to provide Continuing Education (CME or CDE) hours for physicians and dentists. One of the ways to earn CME or CDE credits is by taking a test after reading this issue of Protector. Online access will make it easy for you to complete the test that accompanies this issue.

MedPro insureds who pass two tests in the same policy year might be eligible to earn premium credits. For more information, please review the inside cover of this issue. Or, visit our website at www.medpro.com.

As always, your comments and suggestions are welcome.

Sincerely,

Laura M. Cascella, MAClinical Risk Management Writer/Editor

The term “medical error” often conjures thoughts of wrong site surgeries, procedures performed on the wrong patients, foreign objects left inside patients, medication mistakes, and other serious mishaps.

Although these errors certainly deserve attention, the visibility surrounding them can easily overshadow common, but less sensational lapses. Diagnostic errors, for example, “commonly occur with dire human and economic consequences.”1 Although these errors have sometimes taken a backseat in national patient safety efforts, they have been a long-standing medical malpractice concern.

Over the years, Medical Protective has monitored and analyzed diagnosis-related claims to better understand how and why diagnostic errors occur and to develop comprehensive risk education for insureds.

This issue of Protector continues our commitment to that education; the articles contained herein provide an overview of the issues surrounding diagnostic errors and examine detailed data that show how these errors contribute to malpractice allegations and claims.

The Scope of the Problem

Diagnostic errors occur at an “appreciable, though unknown, rate.”2 Some estimates suggest that the diagnostic error rate is in the range of 10–15 percent, with variations across specialties.3 Further, the authors of a 2011 study about ways to reduce diagnostic errors note that errors associated with diagnosis are more likely to be preventable and more likely to result in patient harm than other types of medical errors.4

Yet, if diagnostic errors represent such a significant burden, why are they so often the wallflowers of patient safety and quality initiatives? Although it’s difficult to find a definitive reason, a number of factors might be at play. For example, diagnostic errors may receive inadequate attention because (a) they often go unrecognized or unreported, (b) they can be difficult to understand and measure, and (c) they don’t always have clear-cut solutions.5

In the last decade, however, various circumstances have pushed diagnostic errors closer to the limelight. A 2013 article about diagnostic error detection lists the following reasons for the increased attention:

n New models of care delivery, such as accountable care organizations, that reward clinicians for correct diagnoses;

n Greater focus and financial support as a result of the formation of the Society to Improve Diagnosis in Medicine;

n Advocacy on the part of the American Medical Association’s Center for Patient Safety;

n High-profile cases, such as a child who died of septic shock after being diagnosed with a minor stomachache;

n Health information technology (HIT) opportunities, including alerts and alarms built into electronic health record systems; and

n Increasing emphasis on team decision-making, particularly for rare and serious conditions.6

Laura M. Cascella, MA

Diagnostic Errors: A Closer Look at a Persistent Risk

Diagnostic errors generally fall into three broad categories:

n Delayed diagnosis: An error that occurs if sufficient information is available to make a correct diagnosis, but the information is not acted upon in a timely manner.

n Wrong diagnosis: An error that occurs if an incorrect diagnosis is made prior to the correct diagnosis.

n Missed diagnosis: An error that occurs if no correct diagnosis is ever made.

Source: Phua, D. H., & Tan, N. C. (2013). Cognitive aspect of diagnostic errors. Annals of the Academy of Medicine, Singapore, 42(1), 33–41.

Although these factors represent important strides, recent literature focusing on diagnostic errors notes the need for additional research to identify gaps in the diagnostic process and study various risk-reduction techniques.

Learning From Malpractice Claims Data

Despite a historic lack of attention, diagnostic errors result in a higher frequency of malpractice claims (for physicians) and larger average indemnities than other types of allegations (for both physicians and dentists).7 A 2013 Medscape article explains that “although malpractice claims may not be a representative measure of adverse events [related to diagnostic errors], they can provide insight into the types and sources of adverse events.”8

With this in mind, the following data from the National Practitioner Data Bank (NPDB) and Medical Protective* help illustrate the impact of diagnostic errors on both the medical and dental communities.

*Medical Protective has teamed up with CRICO Strategies (a division of the Risk Management Foundation of the Harvard Medical Institutions). Using CRICO’s sophisticated coding taxonomy to code claims data, Medical Protective is better able to identify clinical areas of risk vulnerability. All subsequent data attributed to Medical Protective represent a snapshot of Medical Protective’s experience with diagnosis-related claims, including a deep dive into risk factors that drive the claims.

Types of Diagnostic Errors

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53%

15% 14%

18%

n Diagnosis-Related

n Surgery-Related

n Anesthesia-Related

n Others

n Surgery-Related

n Treatment-Related

n Anesthesia-Related

n Diagnosis-Related

n Medication-Related

n Others

Figure 1. Percentage of Claims by Allegation Type, 2004–2013

Source: NPDB Public Use File, Dec. 2013

Figure 2. Average Indemnity by Allegation Group, 2004–2013

Source: NPDB Public Use File, Dec. 2013

Figure 3. Diagnosis-Related Allegations by Condition

Source: Medical Protective coded claims data, 2001–2010

Various factors can contribute to diagnostic allegations (see Figure 4). Contributing factors are broad areas of concern that may play a role in allegations, injuries, or initiation of claims. For both physicians and dentists, clinical judgment is the leading factor, occurring (with some variability) in the majority of claims.

Data from the NPDB show that diagnosis-related allegations represent more than half of all physician claims. For dentists, diagnosis-related allegations represent only 10 percent of total claims; however, they are second in average indemnity, trailing only medication-related allegations (see Figures 1 and 2). For both physicians and dentists, the top allegation category within diagnostic allegations is failure to diagnose.9

Analysis of Medical Protective’s diagnosis-related claims from 2001 through 2010 reveals that, for both physicians and dentists, cancer is the condition most frequently associated with these claims (see Figure 3).

For physicians, the top five types of cancer in diagnosis-related allegations are lung/trachea, colorectal, breast, lymphatic/hematopoietic, and prostate. Cancers of the tongue account for one-third of cancer-related dental claims, followed by cancers of the gums and cheeks. (Note: These rankings are related to the data source noted, and may vary across data sources.)

14%

37%

12% 37%

n Cancer

n Infections/Infectious Disease

n Acute Myocardial Infarction

n Cardiac Disease

n Peripheral Vascular Disease

n Benign Neoplasm

n Cerebrovascular Accident

n Appendicitis

n Fx/Disloc/Sprain/Strain

n Behavioral

n Other

n Cancer

n Infectionn Caries

n Other

30%

< 4% ea.

4% 4% 4% 5%

42%

Diagnosis-Related

Surgery-Related

Anesthesia-Related

Others

$327

$243

$300

$341

Thousands

PHYSICIAN

PHYSICIAN PHYSICIAN

Surgery-Related

Treatment-Related

Anesthesia-Related

Diagnosis-Related

Medication-Related

Others

$60

$45

$71

$91

$115

$46

Thousands

DENTIST

DENTIST DENTIST

(Continued on page 32)

38%

2%1%

10% 15%

34%38%

Figure 4. Root Causes/Contributing Factors for Diagnosis-Related Claims

PHYSICIANS AND DENTISTS

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%Sour

ce: M

edic

al P

rote

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e co

ded

cla

ims

data

, 200

1–20

10 95%

37%

26%21%

14% 13%

6%

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Laura M. Cascella, MA

Clinical Judgment: Let’s Think About Thinking

If you’ve ever heard someone use the phrase, “it was a judgment call,” you probably assumed that the person made a decision based on the best available information. That is, the person assessed the situation, considered relevant data, and came to a conclusion based on factual information and his or her own opinion.

The term “clinical judgment” refers to a similar process, namely “the application of information based on actual observation of a patient combined with subjective and objective data that lead to a conclusion.”1 A 2011 article in the Journal of Evaluation in Clinical Practice explains that “Clinical judgment is developed through practice, experience, knowledge and continuous critical analysis. It extends into all medical areas: diagnosis, therapy, communication and decision making.”2

Because clinical judgment is a complex process that involves various cognitive functions, it’s easy to understand why it is the driving force behind the majority of diagnosis-related malpractice allegations for both physicians and dentists. Further, the prevalence of clinical judgment issues is almost surely tied to the fact that they tend to be less amenable to “simple” fixes than other contributing factors, such as system failures.

This Protector article will (a) take a closer look at the various judgment issues that contribute to diagnosis-related malpractice claims, (b) examine how cognition shapes clinical reasoning and decision-making, (c) discuss how cognitive errors in judgment can occur during the diagnostic process, and (d) explore proposed solutions and risk strategies for managing clinical judgment issues.

Clinical Judgment in the Context of Malpractice

The concept of clinical judgment as a contributing factor to malpractice claims can be difficult to grasp because of its enormity. Simply stated, clinical judgment is a broad category that includes the clinical areas shown in Figure 1.

medications appropriate for the patient’s condition.

Allegations associated with patient monitoring mainly

involve monitoring a patient’s response to a treatment plan.

Although these examples help define the ways in which clinical

judgment errors may contribute to malpractice claims, they don’t

explain why these circumstances happen. What causes these missteps and lapses in judgment? Understanding the clinical reasoning and decision-making processes can help explain why clinical judgment so frequently contributes to diagnostic errors.

Clinical Reasoning and Decision-Making

When making diagnoses, doctors must “reframe patient symptoms into clinical problems” and attempt to solve these problems, which “may not be unambiguously true or false.”3 Much of the literature focusing on diagnostic errors and clinical reasoning recognizes the dual decision-making model as the basis for clinicians’ diagnostic process.

Within clinical judgment, patient assessment issues rise to the top for physicians and dentists. Common examples of patient assessment issues are:

n Failure or delay in diagnostic testing;

n Failure to establish a differential diagnosis;

n Maintaining a narrow diagnostic focus;

n Lack of, or inadequate, patient history and physical;

n Failure to rule out or act on abnormal findings; and

n Misinterpretation of diagnostic test results.

The other categories included in clinical judgment are failure or delay in obtaining a consultation, selection and management of therapy, and patient monitoring. Issues related to selection and management of therapy are heavily focused on choosing an appropriate plan of care, including procedural care. This category also includes issues with ordering

PHYSICIANS AND DENTISTS

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

Figure 1. Leading Issues Associated With Clinical Judgment Source: Medical Protective coded claims data, 2001–2010

Patient Assessment

Selection and Management

of Therapy

Failure/Delay in Consult

Patient Monitoring

96%

46%

23%

12%

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The dual decision-making model consists of two types of clinical reasoning: Type 1 and Type 2. In Type 1, the reasoning process is automatic, intuitive, reflexive, and nonanalytic. The doctor arranges patient data into a pattern and arrives at a working diagnosis based on previous experience and/or knowledge. In Type 2, the reasoning process is analytic, slow, reflective, and deliberate. This type of thinking is often associated with cases that are complex or with which the doctor is unfamiliar.4,5 Type 1 and Type 2 are not mutually exclusive, and doctors tend to use both, depending on the circumstance. However, research suggests that most clinical work involves Type 1 reasoning.6 Although the automatic, intuitive processes that occur in Type 1 are a requisite part of the thought process and often very effective, they also are vulnerable to cognitive errors. A variety of cognitive errors can occur as part of the clinical reasoning process. Describing each is beyond the scope of this article; however, the following

section attempts to summarize, at a high level, some of the common types and sources of these errors.

Cognitive Errors

Research about the cognitive aspect of diagnostic errors suggests that errors in clinical reasoning often arise from several sources, including knowledge deficits, cognitive biases/faulty heuristics, and affective influences.7

Knowledge Deficits Gaps in knowledge and clinician inexperience might seem like a logical cause of diagnostic errors. Thus, an individual might easily assume that younger, less practiced doctors

would be more susceptible to diagnostic pitfalls. In reality though, “The majority of cognitive errors are not related to knowledge deficiency but to flaws in data collection, data integration, and data verification,”8 with “data” referring to clinical information obtained during the doctor–patient encounter.

Further, many diagnostic errors are associated with common diseases and conditions, suggesting that other problems with clinical reasoning — such as faulty heuristics, cognitive biases, and affective influences — are the more likely culprit (as opposed to poor knowledge).

Faulty Heuristics and Cognitive Biases The term “heuristics” refers to mental shortcuts in the thought process that help conserve time and effort. These shortcuts are an essential part of thinking, but

they are also prone to error. Cognitive biases occur when heuristics lead to faulty decision-making.9 Some common biases included anchoring, availability, and overconfidence.

Anchoring. This bias refers to a snap judgment or tendency to diagnose based on the first symptom or lab abnormality. Anchoring is closely related to several other biases, including:

n Under-adjustment, which is the inability to revise a diagnosis based on additional clinical data.

n Premature closure, which is the termination of the data-gathering process (e.g., patient history, family history, and medication list) before all of the information is known.

n Primacy effect, which is the tendency to show bias toward initial information.

n Confirmation bias, which occurs if a clinician manipulates subsequent information to fit an initial diagnosis.

Availability. This bias can occur if a clinician considers a diagnosis more likely because it is forefront in his or her mind. Past experience and recent, frequent, or prominent cases can all play a role in availability bias. For example, a doctor who has recently diagnosed an elderly patient with dementia might be more likely to make the same diagnosis in another elderly patient who has signs of confusion and memory loss — when, in fact, the patient’s symptoms might be indicative of another problem, such as vitamin B12 deficiency.

Overconfidence bias. This bias refers to “over-reliance on one’s own ability, intuition, and judgment.”10 Overconfidence might result from a lack of feedback related to diagnostic accuracy, which may in turn cause clinicians to overestimate their diagnostic precision. As such, researchers suggest

that overconfidence might increase as a doctor’s level of expertise increases.11

Affective InfluencesWhereas cognitive biases are lapses in thinking, the term “affective influences” refers to emotions and feelings that can sway

clinical reasoning and decision-making.12 For example, preconceived notions and stereotypes about a patient might influence how the doctor views the patient’s complaints and symptoms.

If the patient has a history of substance abuse, for instance, the doctor might view complaints about pain as drug-seeking behavior. Although this impulse might be accurate, the patient could potentially have a legitimate clinical issue.

Additionally, certain factors might trigger negative feelings about a patient that can cause the clinician to inadvertently judge or blame the patient for his or her symptoms or condition. For example, a patient’s obesity might be attributed to laziness or general disregard for his or her health. Or, a patient who is noncompliant with follow-up care might be viewed as difficult, when, in reality, the noncompliance is related to financial issues.

Research about the cognitive aspect of diagnostic errors suggests that errors in clinical reasoning often arise from several sources...

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gender, socio-economic status, and ethnicity — also can affect the diagnostic process. Consider that research has suggested that women are less likely than men to have complaints about pain taken seriously, and they are less likely than men to received aggressive treatment for pain.14

A variety of other factors also can affectively influence a doctor’s reasoning, such as:

n Environmental circumstances, e.g., high levels of noise or frequent interruptions;

n Sleep deprivation, irritability, fatigue, and stress; and

n Mood disorders, mood variations, and anxiety disorders.15

The complex interaction between these influences and cognitive biases can have a profound effect on clinical reasoning and decision-making, which in turn can lead to various lapses in clinical judgment.

Case Examples

In a 2008 article titled “Why Doctors Make Mistakes,” Dr. Jerome Groopman discusses how negative feelings can lead to attribution bias, a type of affective influence. Dr. Groopman notes that this type of bias accounts for many diagnostic errors in elderly patients. For example, clinicians might have a tendency to attribute elderly patients’ symptoms to advancing age or chronic complaining, rather than exploring other potential causes.13

Positive feelings about patients also can affect diagnostic decisions. In outcome bias, for example, a doctor may overlook certain clinical data in order to select a diagnosis with better outcomes. By doing so, the doctor is placing more value on what he or she hopes will happen, rather than what might realistically happen.

In addition to positive and negative feelings about patients, clinician and patient characteristics — such as age,

Case 1Overview: A 34-year-old male presented to his primary care doctor with sternal pain after lifting a boat in his backyard. The pain increased when the patient raised his arms. An ECG was ordered, and the results were negative. The patient was not referred for cardiac enzyme testing, because the doctor determined that muscle strain was the cause of the patient’s symptoms. The doctor cleared the patient to go on vacation. Two days into his vacation, the patient died from a heart attack.

Discussion: This case offers a good example of the anchoring bias. Knowing that the patient had recently lifted a boat, the doctor honed in on muscle strain as the likely cause of the patient’s pain. This narrow diagnostic focus was bolstered by the negative ECG. As a result, the doctor failed to order further testing and prematurely terminated the data-gathering process. Further investigation would have likely revealed that the patient was a heavy smoker and drinker. He also had a family history of cardiovascular disease, and both his father and grandfather died in their early forties. An affective influence may have been at play in this case as well. That is, the doctor might have considered a cardiac condition less likely based on the patient’s age.

Case 2Overview: A patient who had undergone radiation therapy for cancer of the soft palate presented to his general dentist for routine care. Because of severe xerostomia, the dentist and patient were unable to control the patient’s caries. After multiple attempts to restore the severely compromised teeth, the dentist decided to remove the remaining mandibular teeth and insert a complete lower denture; however, he did not suggest any precautionary measures, such as hyperbaric oxygen, prior to the extractions. After a series of denture adjustments, the soft tissue on both the right and left mandibular ridges did not heal, and the patient would periodically remove small pieces of bone. The patient returned to the general dentist on at least seven different occasions to complain about the discomfort, bone spicules, a foul odor in his mouth, and episodes of swelling. After approximately 1 year, the general dentist referred the patient to an oral and maxillofacial surgeon. The surgeon developed a plan of care for the patient that included hyperbaric oxygen treatments and removal of the remaining maxillary teeth, as well as repair of the mandibular defects. During the course of treatment, the oral surgeon noted that the mandible was fractured. External fixation and a bone graft were required to stabilize the fracture.

Discussion: A number of lapses in clinical judgment complicated this case and ultimately led to a malpractice claim against the general dentist. The first was the issue of selecting and managing the patient’s therapy. Prior to removal of the mandibular teeth, the dentist did not recommend a hyperbaric oxygen protocol or other precautionary measures, despite the patient’s medical history. Following the procedure, the patient presented on multiple occasions with complaints, but the dentist failed to identify the underlying issue or recommend treatment. Finally, the delay in referring the patient to an oral surgeon was alleged to have contributed to the patient’s poor outcome. A knowledge deficit also may have contributed to this case, as the dentist had limited experience with cases of this level of severity. Additionally, overconfidence might have been a factor in the dentist choosing to manage the case himself instead of providing an immediate referral.

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Proposed Solutions

Although cognitive processes are well-studied, further research is needed to determine how best to prevent the flaws in clinical judgment that can lead to diagnostic errors. A number of strategies and solutions have been proposed, which range from the use of diagnostic aids, to process changes, to debiasing techniques. For example, some researchers suggest that the use of evidence-based decision support systems, clinical guidelines, checklists, and clinical pathways can help support the clinical reasoning and decision-making processes. However, they note that although these tools can be useful, “unless they are well integrated in the workflow, they tend to be underused.”16

Additionally, incorporating a diagnostic review process into the workflow pattern might be helpful. The review may include timeouts to consider and reflect on working diagnoses, as well as the solicitation of second opinions.

A variety of techniques to reduce cognitive bias and affective influences have also been proposed, including training in situational awareness and

metacognition, so that clinicians can think critically about their own thought processes and how biases might affect them. These techniques may include cognitive forcing functions, which are strategies designed to help clinicians self-monitor decisions and avoid potential diagnostic pitfalls.17

Although many of these techniques show promise, more research is needed to evaluate their efficacy and to determine the feasibility of introducing them into busy practice environments.

Risk Management Strategies

As researchers continue to explore long-term solutions to errors in clinical judgment, doctors can proactively implement strategies to help mitigate risks associated with clinical reasoning, cognition, and decision-making. The following list offers broad suggestions for managing these risks within medical and dental practices.

n Perform complete patient assessments, including establishment of a differential diagnosis, appropriate consideration of diagnostic testing, and careful review of test results.

n Update and review patients’ medical histories, problem lists, medication lists, and allergy information on a regular basis.

n Implement and utilize clinical pathways to standardize processes and support quality care.

n Consider the use of decision support systems, diagnostic timeouts, consultations, and group decision-making to support clinical reasoning.

n Formalize procedures for over-reads of diagnostic tests and imaging, peer review and quality improvement, use of diagnostic guidelines, and better access to patients’ records.

n Be aware of common cognitive biases and how they might negatively affect clinical judgment.

n Consider group educational opportunities that allow doctors to explore cognitive biases and form working solutions together.

Conclusion

Although diagnostic errors have a number of root causes, clinical judgment is by far the most common contributing factor. The complex nature of clinical reasoning and decision-making makes it vulnerable to cognitive biases and affective influences. These errors can subconsciously lead to lapses in judgment, which in turn can cause diagnostic mistakes.

More studies are needed to determine effective approaches for addressing cognitive errors. However, a number of strategies — such as decision support systems, clinical pathways, checklists, reflective practice, and cognitive awareness — show promise. By considering how these strategies can be implemented in everyday clinical activities, physicians and dentists can begin to take steps toward managing diagnostic risks.

Endnotes 1 http://medical-dictionary.thefreedictionary.com/

clinical+judgment

2 Kienle, G. S., & Kiene, H. (2011, August). Clinical judgment and the medical profession. Journal of Evaluation in Clinical Practice, 17(4), 621–627.

3 Phua, D. H., & Tan, N. C. (2013). Cognitive aspect of diagnostic errors. Annals of the Academy of Medicine, Singapore, 42(1), 33–41.

4 Nendaz, M., & Perrier, A. (2012, October). Diagnostic errors and flaws in clinical reasoning: Mechanisms and prevention in practice. Swiss Medical Weekly, 142:w13706.

5 Ely, J. W., Graber, M. L., & Crosskerry, P. (2011, March). Checklists to reduce diagnostic errors. Academic Medicine, 86(3), 307–313.

6 Nendaz, et al., Diagnostic errors and flaws in clinical reasoning; Crosskerry, P., Singhal, G., & Mamede, S. (2013, October). Cognitive debiasing 1: Origins of bias and theory of debiasing. BMJ Quality & Safety, 22(Suppl 2), ii58–ii64.

7 Phua, et al. Cognitive aspect of diagnostic errors.

8 Nendaz, et al., Diagnostic errors and flaws in clinical reasoning.

9 Phua, et al. Cognitive aspect of diagnostic errors.

10 Pilcher, C. A. (2011, March 31). Diagnostic errors and their role in patient safety. MedPage Today. Retrieved from http://www.kevinmd.com/blog/2011/03/diagnostic-errors-role-patient-safety.html

11 Clark, C. (2013, August 27). Physicians’ diagnostic overconfidence may be harming patients. HealthLeaders Media. Retrieved from http://www.healthleadersmedia.com/content/QUA-295686/Physicians-Diagnostic-Overconfidence-May-be-Harming-Patients##; Phua, et al., Cognitive aspect of diagnostic errors.

12 Crosskerry, P., Abbass, A. A., & Wu, A. W. (2008, October). How doctors feel: Affective influences in patient’s safety. Lancet, 372, 1205–1206; Phua, et al. Cognitive aspect of diagnostic errors.

13 Groopman, J. (2008, September/October). Why doctors make mistakes. AARP Magazine, p. 34.

14 Hoffman, D. E., & Tarzian, A. J. (2001). The girl who cried pain: A bias against women in the treatment of pain. Journal of Law, Medicine, and Ethics, 29, 13-27.

15 Crosskerry, P., et al., How doctors feel.

16 Ely, et al., Checklists to reduce diagnostic errors.

17 Crosskerry, P. (2003). Cognitive forcing strategies in clinical decisionmaking. Annals of Emergency Medicine, 41, 110–120.In 2013, the Society to Improve Diagnosis in Medicine (SIDM)

developed a clinical reasoning toolkit for trainees, clinicians, and teachers. The SIDM toolkit supports awareness and better understanding of diagnostic reasoning, cognitive psychology, and diagnostic errors.

Resources within the toolkit include links to books and articles, slide presentations, and videos focusing on clinical reasoning and cognitive errors. For more information, visit https://improvediagnosis.site-ym.com/?ClinicalReasoning

Online Resource: Clinical Reasoning Toolkit

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What We Have Here Is a Failure to Communicate (and Strategies to Prevent Communication Failures)

judgment as a contributing factor in malpractice claims, based on Medical Protective claims data. Although MedPro’s data show that communication issues have decreased over time, they still remain a persistent factor in claims and occur at a palpable rate (see Figure 1).

In a broad sense, communication failures can be broken down into two main categories: communication issues among providers (and their staff members) and communication lapses between providers and patients. This article will

In terms of diagnosis, certain elements of the patient care process might be particularly vulnerable to communication missteps and errors, such as coordination of care or transitions of care among

multiple providers and medical staff. These providers and staff members might be working in the same practice or coordinating care across various organizations. Further, the scenario in which information is exchanging hands can vary. For example, a doctor might be providing coverage for another clinician, ordering

diagnostic procedures, referring a patient to a specialist (or receiving a referral), or participating in multidisciplinary care.

Providing coordinated, competent patient care involves precision at many points in the clinical process, but particularly in sending and receiving information. Yet, “the increasingly complex healthcare environment can complicate the communication process and hinder the information exchanges necessary for optimum care.”1

Communication breakdowns in healthcare are not uncommon, and they can result in anything from minor confusion to serious patient harm. In terms of diagnostic errors, communication issues fall in second behind clinical

examine both and will discuss various ways in which physicians and dentists can implement safeguards in their communication processes.

Communication Issues Among Healthcare Providers and Staff Members

Successful communication among healthcare providers and between providers and their staffs has always been a critical element of patient safety. The emphasis on communication has been even more pronounced in recent years, with the shifting focus toward collaborative and team-based care. As noted in the fall 2013 issue of Protector, the Institute of Medicine lists communication as one of the five core principles guiding new models of care delivery.2

However, even as the demand for collaborative care increases, communication still remains a top risk issue in medical and dental practices. Further, “legal dangers appear to be on the rise as team-based care grows and patients are handed off to a wider scope of health professionals.”3

Laura M. Cascella, MA

In terms of diagnosis, certain elements of the patient care process might be particularly vulnerable to communication missteps and errors…

Figure 1. Trends in Diagnostic Error Contributing Factors Over a 10-Year PeriodSource: Medical Protective coded claims data, 2001–2010

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Regardless of the situation, care coordination and care transitions require careful communication among providers and healthcare facilities, accountability for assigned roles, ownership of established processes, and engagement with providers and patients.4 When evaluating your practice’s efforts to support continuity and coordination of care, consider whether policies are in place that:

n Define the specific types of information to communicate during care coordination or transitions of care, such as the patient’s medical history, family history, known conditions, allergies, medication list, and treatment information.

n Clearly establish duty of care and clinical responsibilities for all providers. For example, who is communicating information to the patient?

n Support thorough and ongoing communication between doctors, advanced practice providers, and clinical staff (through electronic mediums, regularly scheduled meetings, etc.).

n Define appropriate processes for referrals and consultations, such as how the practice intends to handle urgent communication, consultation reports, informed consent, and follow-up.

n Outline a plan for communication of pertinent clinical findings or critical test results.

n Establish requirements for using tools, checklists, and forms as part of the care coordination process.

n Define expectations for documentation in the patient record.

Because care coordination involves many components and individuals, as well as complex logistical processes, physicians and dentists may feel limited in their ability to manage all of the moving parts and effect change — especially when

working with individuals and groups outside of their practices. However, taking steps within the practice to address gaps in, and enhance policies related to, care transitions and continuity of care

can make a difference. A 2014 Medical Economics article notes that doctors can “build a rigorous transition of care process”5 within their organizations by implementing proactive strategies. Examples of these strategies include formalizing inbound patient referral processes, focusing on the logistics of external referrals, and finding opportunities to improve collaboration with other providers.

Communication Issues Between Providers and Patients

Communicating well with patients is vital in establishing a culture of safety, creating a doctor–patient partnership, and engaging patients in shared responsibility for their medical or dental care. Failures or gaps that occur in doctor–patient communication may increase the likelihood of errors, including diagnostic errors. Further, some malpractice studies suggest that doctors who are poor communicators are more likely to be sued. A study in Florida showed that the way in which patients perceive doctors’ “interest, accessibility, and communications ability was more important than the technical quality of care as a predictor of the physician’s malpractice claiming experience.”6

Case Example Overview: A 45-year-old male presented to his primary care doctor complaining of a headache of 2 weeks duration. The patient was morbidly obese, had a family history of cerebral aneurysm and migraine headaches, and was a heavy smoker.

The primary care doctor ordered an MRI and MRA of the brain, which were read by a neuroradiologist at a teleradiology service. The neuroradiologist reported a 3 millimeter aneurysm of the anterior communicating artery. Based on this information, the primary care doctor referred the patient to a neurosurgeon.

When the patient presented to the neurosurgeon, he brought hard copies of both the MRI and MRA. The neurosurgeon reviewed the patient’s hard copies, but never looked at the full motion source images. Based on the still images, the neurosurgeon concluded that the patient did not have an aneurysm.

About 18 months later, the patient woke with an abrupt, severe headache. At the hospital, a CT angiogram confirmed a hemorrhage in the brain, most likely caused by a 5 millimeter aneurysm.

Despite treatment, the patient was diagnosed as brain dead and he died shortly thereafter.

Discussion: When multiple providers are involved in a patient’s care, the opportunity for miscommunication increases — particularly when the providers are in different locations. In this case, the neurosurgeon potentially missed signs of the aneurysm because he did not have access to all of the images that were available to the neuroradiologist.

However, the neurosurgeon did have access to the neuroradiologist’s report. A careful review of the report would have indicated a difference of opinion in the diagnosis. At that point, the neurosurgeon could have arranged a call with the neuroradiologist to discuss and reconcile their differing opinions about the test results.

Better communication between these specialists may have ultimately led to a different course of action and possibly a different outcome for the patient.

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Thus, the ability to effectively interact with patients is essential in all steps in the care process — from initial encounter through follow-up.

Communication Policies

To help mitigate the risk of poor communication with patients, physicians and dentists should consider developing comprehensive policies related to verbal, electronic, and written communication with patients.

These policies should:

n Establish expectations for courteous, respectful communication that is reflective of a patient-centric, service-oriented culture.

n Describe the purpose and accepted use of each type of communication and explicitly note the preclusion of certain activities (such as diagnosing over the phone or email).

n Set forth standards and criteria for telephone triage that (a) support scheduling based on patient needs, (b) establish the use of boilerplate responses and scripts (when appropriate), and (c) assign roles for clinical and nonclinical staff.

n Define the appropriate use of email and social media for communicating with patients, including management of accounts, development of disclaimer language, and staff roles.

n Establish appropriate timeframes for clinician response to verbal and electronic inquiries and concerns.

n Outline steps for managing patient complaints and measuring patient satisfaction (for example, through the use of surveys).

n Delineate a process and appropriate timeframes for following up with patients about test results and missed or cancelled appointments.

n Define specific requirements for documenting patient interactions within the patient’s record.

n Support staff education and training on communication procedures and techniques.

Doctor–Patient Encounters

A 2013 study that focused on the types and origins of diagnostic errors in primary care found that more than 75 percent of the process breakdowns that led to diagnostic errors involved the practitioner–patient encounter.7

What goes wrong during these interactions?

Although it’s not always clear, various office-, doctor-, and patient-related circumstances can play a role, such as:

n Environmental factors, e.g., ongoing distractions or interruptions.

n Situations in which patients do not feel comfortable reporting their symptoms or medical/dental histories.

n Circumstances in which doctors prematurely cut off patients while they’re talking. Research has shown that, on average, doctors will interrupt patients within the first 18 seconds of telling their story.8

To help mitigate the risk of poor communication with patients, physicians and dentists should consider developing comprehensive policies related to verbal, electronic, and written commun ication with patients.

Overview: A doctor on call for his group practice received an after-hours call from a male patient in his sixties. The patient was complaining of weakness and reported that he had started a new blood pressure pill — hydrochlorothiazide — 3 days earlier. He also reported taking lisinopril daily for more than a year. The doctor quickly attributed the patient’s weakness to the new medication; he told the patient to stop taking the hydrochlorothiazide and to check his blood pressure using a home blood pressure cuff. The doctor instructed the patient to seek immediate care if his systolic pressure went above 180 mmHg, but to otherwise make an appointment to see his regular doctor to get a different blood pressure medication.

Three days later, the patient was hospitalized with sudden onset of right arm and leg weakness, as well as difficulty speaking. He was diagnosed with atrial fibrillation. Based on the patient’s symptoms and medical history, the admitting physician determined that the patient’s weakness was a result of the arrhythmia, rather than the side effects of hydrochlorothiazide. The findings on neuroimaging strongly suggested an embolic stroke. The patient was treated with warfarin for the atrial fibrillation and received rehabilitation while in the hospital; however, he was still experiencing weakness and some word-finding difficulties 6 weeks later.

Discussion: This case demonstrates several communication problems (as well as clinical judgment issues). Because the doctor was conversing with the patient over the phone, he did not have the benefit of performing a complete physical or gathering visual evidence of the patient’s condition. Thus, taking the patient’s history became the most crucial aspect of the encounter. However, once the patient reported his new blood pressure medication, the doctor focused on that information (anchoring bias) and terminated the data-gathering process (premature closure).

Further, when speaking with the patient, the doctor did not ask open-ended questions about the patient’s symptoms — e.g., “How would you describe the weakness?” This strategy may have revealed further information about the patient’s condition, which potentially could have indicated the severity of the patient’s situation. Finally, other than noting that the patient should seek immediate care if his systolic pressure rose above 180 mmHg, the doctor did not provide the patient with any further instructions, such as what to do if the weakness continued or worsened, how to respond if new symptoms occurred, or when to schedule the follow-up appointment.

Case Example

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gathering information, (b) build patient trust, and (c) reinforce a culture of safety — critical elements for improving the diagnostic process, reducing the risk of errors, and preventing liability claims.

Patient Comprehension

A major obstacle in doctor–patient communication is ensuring patient comprehension of both verbal and written health information, including clinical explanations, recommendations, instructions, educational materials, and more.

Health information and services are often unfamiliar and confusing, and people of all ages, races, cultures, incomes, and educational levels may struggle with health literacy. In fact, the Institute of Medicine says that nearly half of all American adults have trouble understanding and acting on health information.9 Further, the CDC explains that almost 90 percent of adults have difficulty using the everyday health information that is routinely available in healthcare facilities.10

In addition to limited health literacy, other issues — such as language barriers and auditory, visual, or speech disabilities — can hinder the communication process and patient understanding.

Because “obtaining, communicating, processing, and understanding health information and services are essential steps in making appropriate health decisions,”12 gaps in these areas can have serious implications for informed

consent/refusal, patient follow-up, and patient compliance.

Thus, taking steps to ensure patient understanding and awareness is critical to your practice’s communication strategies. The checklist on page 23 can help you identify patient comprehension

strategies already at work in your practice and target areas for improvement.

As with other aspects of the patient care process, activities related to informed consent discussions, consultative advice, clinical recommendations, and patient education should be documented in the patient record.

Plain Language The principles of plain language focus on communication that is clear, concise, and logically organized. For written materials, the reader should be able to find what they need, understand what they find, and use what they find to meet their needs.11 Resources are available to help healthcare providers better understand plain language and its role in health literacy. Examples of these resources include:

n PlainLanguage.gov http://www.plainlanguage.gov/index.cfm

n Plain Language (NIH) http://www.nih.gov/clearcommunication/plainlanguage/index.htm

n Toolkit for Making Written Material Clear and Effective (CMS) http://www.cms.gov/Outreach-and-Education/Outreach/WrittenMaterialsToolkit/index.html?redirect=/WrittenMaterialsToolkit/

Strategies to Enhance Communication During the Doctor–Patient Encounter n Allow adequate time for dialogue, and take the time to understand the patient’s/family’s

concerns and point of view.

n Make an effort to allow patients to fully voice their concerns without interruption.

n Repeat key information back to the patient after he or she has finished explaining the chief complaint or reason for the visit.

n Determine what the patient hopes to achieve as a result of the visit.

n Whenever possible, sit down with the patient while taking his or her history or reviewing clinical information.

n Ask open-ended questions to generate more thorough information. For example, “So, you’re having pain?” becomes “Can you tell me more about your pain?”

n Create an atmosphere that encourages questions and open dialogue. Specifically ask whether the patient has questions or would like to offer any additional information before the appointment concludes.

n Use eye contact in face-to-face conversation. Eye contact is increasingly more important as technologies, such as electronic health records (EHRs), are used in the office practice environment.

n Consider your body language and how a patient might perceive it. For example, fidgeting or constantly looking at a computer screen might be construed as dismissive. Certain facial expressions might be considered judgmental, which may cause the patient to withhold information.

n Situations in which patients or their family members feel that their doctors are devaluing their views or failing to understand their perspectives.

These issues, alone or in combination, can lead to communication breakdowns, problems with data collection and synthesis, patient dissatisfaction, and — ultimately — diagnostic mistakes.

Tackling doctor–patient communication issues can be tricky due to the somewhat

nebulous nature of these problems. However, various techniques and strategies can be employed to enhance interactions with patients, build better doctor–patient partnerships, and engage patients in the diagnostic process, as shown in the box below.

Although these strategies will not eliminate the potential for miscommunication, they may help doctors (a) improve their processes for

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Verbal and written health information and instructions are provided in lay language, and medical terms are explained. (For example, “shortness of breath” is used instead of “dyspnea,” or “tooth decay” instead of “caries.”)

Patient forms and educational materials adhere to the principles of plain language (see box on page 21).

The quantity of information provided is reflective of “need to know,” essential facts. Information does not include extraneous details that could distract the reader and potentially inhibit understanding.

When possible, and with the patient’s permission, family members and significant others are included in discussions about the patient’s care.

The patient’s overall capacity to understand, language barriers, cultural beliefs, and disabilities are considered as part of communication strategies.

Access to language services, interpreters, and assistive technology is available to meet patients’ diverse needs.

Instructions for follow-up care are provided verbally and reinforced in writing. Written versions are updated as changes occur.

The informed consent process is tailored to the specific patient and the complexity of the proposed intervention.

The practice’s philosophy on informed consent reinforces that, for the patient to be truly “informed,” he or she must understand the information that the healthcare provider has disclosed.

“Teach-back” or “repeat-back” techniques are used to gauge patient understanding and reduce the risk of miscommunication.

Questions are encouraged, and time for questions and review of materials is allotted during patient appointments.

3 Gallegos, A. (2014, July 15). Medical liability: Missed follow-ups a potent trigger of lawsuits. American Medical News. Retrieved from http://www.amednews.com/article/20130715/profession/130719980/2/

4 Woodcock, E. W. (2014, March). Seven steps for managing transitions of care. Medical Economics. Retrieved from http://medicaleconomics.modernmedicine.com/medical-economics/news/seven-steps-managing-transitions-care?page=full

5 Ibid.

6 Robert Wood Johnson Foundation. (2002, September). Counseling of physicians at high risk of malpractice claims lowers the level of patient complaints. Retrieved from http://www.rwjf.org/en/research-publications/find-rwjf-research/2002/09/counseling-of-physicians-at-high-risk-of-malpractice-claims-lowe.html

7 Singh, H., Giardina, T. D., Meyer, A. N., Forjuoh, S. N., Reis, M. D., & Thomas, E. J. (2013, March 25). Types and origins of diagnostic errors in primary care settings. JAMA Internal Medicine, 173(6), 418–425

8 Levine, M. (2004, June 1). Tell the doctor all your problems, but keep it to less than a minute. The New York Times. Retrieved from http://www.nytimes.com/2004/06/01/health/tell-the-doctor-all-your-problems-but-keep-it-to-less-than-a-minute.html

9 Nielsen-Bohlman, L., Panzer, A. M., & Kindig, D. A. (Eds.). (2004). Health literacy: A prescription to end confusion. Institute of Medicine. Washington, DC: The National Academies Press.

10 The Centers for Disease Control and Prevention. (2011). Health literacy: Learn about health literacy. Retrieved from http://www.cdc.gov/healthliteracy/learn/index.html

11 PlainLanguage.gov. (n.d.). What is plain language? Retrieved from http://www.plainlanguage.gov/whatisPL/index.cfm

12 Ibid.

13 Groopman, J. (2007, March 15). Excerpt: How doctors think. NPR Books. Retrieved from http://www.npr.org/2007/03/16/8946558/groopman-the-doctors-in-but-is-he-listening#8894868

ConclusionDr. Jerome Groopman, in his book titled How Doctors Think, states that although “modern medicine is aided by a dazzling array of technologies . . . language is still the bedrock of clinical practice.”13 This sentiment holds true when examining the ways in which communication gaps or failures contribute to diagnostic errors and subsequent malpractice claims.

Although Medical Protective data show that communication considerably trails clinical judgment as a contributing factor to diagnosis-related claims, it nonetheless represents a consequential risk. Medical and dental practices can potentially mitigate that risk by evaluating collaborative processes among providers, carefully considering communication processes between providers and staff and providers and patients, and developing policies to strengthen and safeguard communication efforts.

Endnotes 1 ECRI Institute. (2014, January). Communication.

Healthcare Risk Control (Suppl A).

2 Mitchell, P., Wynia, M., Golden, R., McNellis, B., Okun, S., Webb, C. E., . . . Von Kohorn, I. (2012). Core principles & values of effective team-based health care. Institute of Medicine. Retrieved from http://www.iom.edu/Global/Perspectives/2012/TeamBasedCare.aspx

Patient Comprehension Checklist

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Contributing Factor Potpourri: How Other Issues Play a Role in Diagnostic Errors

In addition to clinical judgment and communication — the topics covered in the previous two articles — other factors also can play a role in diagnostic errors, such as documentation, clinical system failures/administrative issues, and behavioral problems.

An in-depth analysis of each of these root causes is beyond the scope of this Protector journal; however, this article will broadly define these factors, highlight how they contribute to diagnostic errors, and offer high-level strategies for addressing these risks in the office practice setting.

Documentation

Accurate documentation of all care provided to a patient can be crucial in the defense of a malpractice claim. Medical Protective claims data show that documentation issues occur in approximately 10–15 percent of diagnosis-related claims and generally fall into three categories: insufficient, content, and mechanics (see Figure 1). Insufficient DocumentationAmong the categories represented in Figure 1, insufficient documentation dominates. Examples of situations that can lead to documentation deficits include:

n Failure to document attempts to follow-up with a patient about care or test results.

n Failure of the provider to document that he or she has been involved in a patient’s care.

n Missing documentation in the patient’s record (e.g., patient problem list, test results, consultations, referrals, signatures indicating review, or medication list).

n Failure to document adequate details about the patient encounter. This can be especially problematic in an electronic health record (EHR) due to reliance on form fields and check boxes.

Consider the case on page 25, in which insufficient documentation compounds issues associated with other contributing factors, such as clinical judgment and patient behavior.

The patient was a 65-year-old female who had been seeing her dentist for 20 years. She had an extreme build-up of plaque and calculus, deteriorating teeth, and bleeding gums. The patient was consistently noncompliant with her home oral hygiene instructions. She also would go for long periods between dental appointments — sometimes up to 3 years.

The dentist advised the patient that she had bone loss and tooth mobility, and he recommended that she consult with a periodontist. The dentist also recommended that the patient come in for dental visits every 3 months. The patient insisted on only having yearly visits, and she did not follow through on seeing the periodontist. Eventually, the patient required a full mouth extraction and extensive

specialized care. She then filed a lawsuit against the dentist alleging delay in diagnosis and failure to treat.

Although one could argue that the patient’s noncompliance with her treatment plan and dental appointments played a significant role in her poor dental health, insufficient documentation

complicated matters in this case.

Despite the fact that the patient had been seeing the dentist for two decades, documentation in her dental record was very sparse. The dentist did not document the patient’s general non compliance with her oral hygiene plan, her inconsistency in presenting for

routine care, or any attempts to contact her for follow-up appointments.

Additionally, the doctor failed to document his recommendation that the patient consult with a periodontist. As a result of the incomplete patient record and insufficient documentation, this case presented significant challenges for the defense.

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Figure 1. Diagnosis-Related Claims: Focus on Documentation Source: Medical Protective coded claims data, 2001–2010

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Content-Related Issues and MechanicsThe other two categories under documentation — content and mechanics — refer to a range of issues. Content-related concerns include problems such as altered documentation (which may suggest an attempt to cover-up mistakes), opinions stated as medical facts, inappropriate comments or speculation (e.g., subjective vs. objective information), or general inconsistencies in documentation patterns across records. The mechanics category refers to inaccurate documentation within a factual setting. Examples include inaccuracies in transcribing or writing

orders, illegibility, delays in documenting, and failure to use an appropriate method for correcting documentation errors and making amendments.

Although EHRs can help address some of these issues (such as illegibility), they also can introduce new documentation challenges and potential risks, such as the use of the copy/paste function or the collection of metadata. For more information about documentation issues associated with EHRs, refer to the summer 2013 issue of Protector (available by logging on with your username and password at www.medpro.com).

Documentation Risk Tipsn Ensure your practice’s documentation policies require providers to document:

• Sufficient details related to the patient’s history and physical exam. This will help support continuity of care and comparison of findings from previous visits.

• Patient compliance (or noncompliance), including missed and cancelled appointments. Providers should be careful to remain objective in their documentation and avoid subjective comments and editorializing.

• Treatment plan changes, such as receipt of diagnostic results, follow-up with the patient, patient response, and phone conversations (including after-hours calls).

• Consultations and referrals, including conversations with the consulting provider, agreed-upon consulting arrangements, and receipt and review of consultation reports.

• Patient education, including written and verbal advice, recommendations, and educational materials — as well as patient understanding of the information.

n Establish appropriate timeframes for completion of documentation following patient encounters.

n Consider whether documentation in the record supports your critical thinking process and clearly identifies how a particular diagnosis was determined.

n Do not include incident reports or criticism of other providers in patient records. Root cause analysis of errors and near-misses should be documented as part of the practice’s risk management and quality improvement efforts.

n Understand and educate staff about the appropriate methods for correcting or amending documentation.

YES NO

Ordered tests are scheduled?

Scheduled tests are completed?

Tests results are received by the practice?

The ordering clinician reviews and initials all test results?

A test reporting form and patient notification process are in place?

The doctor follows up on test results?

Test results are filed in the correct patient record?

Decisions about care are documented?

Administrative issues include problems related to medical/dental records, adverse event reporting, staffing, and policies/protocols (specifically, not following existing policies/protocols). Examples of administrative issues include:

n Failure of providers and staff to adhere to established procedures;

n Lack of staff training and education on office systems and processes;

n Inadequate supervision of office and medical staff;

n Failure to verify patient identifiers; and

n Failure of a nurse, advanced practice provider, or dental clinician to contact a doctor when warranted.

Does your practice’s test tracking system have safeguards to ensure that:

Clinical System Failures and Administrative Issues

Clinical systems failures and administrative issues are closely related in that they both deal with inconsistencies in, or problems associated with, a healthcare practice’s processes.

MedPro claims data show that these issues occur in approximately 10 percent of diagnosis-related claims.

Clinical system failures involve breakdowns in office systems and procedures, namely tracking

and follow-up systems. Lapses or gaps in these systems can lead to mistakes and oversights that may ultimately contribute to diagnostic errors. Examples of possible system problems include:

n Lack of, or inadequate, processes for tracking test results, consults/referrals, and patient follow-up (regarding test results, missed/cancelled appointment, etc.);

n Insufficient maintenance of films from radiology studies;

n Delays in, or failure to, receive test results;

n Lack of established timeframes for follow-up; and

n Failure to assign responsibility for follow-up.

Technical issues — such as problems with system interfaces, user errors, software or hardware glitches, and technology failures — also can play a role in clinical system failures.

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Consider the following case, which demonstrates how system failures and administrative issues can cause a delayed diagnosis and patient harm:

A 44-year-old female patient with a history of cervical dysplasia and breast masses/fibroadenomas was being monitored by her long-time OB/GYN doctor. Per her doctor’s instruction, the patient had a breast ultrasound in the office. The images were sent out to an imaging center for analysis. The imaging center promptly reported the results as suspicious for malignancy and recommended a biopsy. Unfortunately, staff at the OB/GYN practice did not follow the appropriate protocol for notifying the physician of

the patient’s results. Thus, the doctor did not review the report, and the report was not filed in the patient’s chart. The patient had an appointment for a mammogram scheduled for approximately 2 weeks after the

ultrasound, but she cancelled the appointment. Subsequently, she made and cancelled two more appointments within a 3-month window. The patient finally returned to the office 10 months after the ultrasound. At that time, her left

breast was red and very firm. A biopsy confirmed invasive ductal carcinoma with lymph node metastases. Although she underwent aggressive treatment, her prognosis was not promising.

Several missteps occurred in this case, the first of which was administrative. The staff at the OB/GYN clinic did not follow the appropriate protocol for managing the information they received from the imaging center. This set in motion a domino effect, in which the results were not appropriately reviewed or filed. Because of this, the patient wasn’t notified of the findings and wasn’t aware of the severity of her situation.

Further complicating the matter was the practice’s “no news is good news” approach to test results. The doctor had not actively involved the patient in the diagnostic process by asking her to follow up if she didn’t receive her results within a specified timeframe. Better patient involvement strategies might have triggered the patient to contact the practice when she didn’t hear from them — thereby incorporating an additional safeguard into the process.

Finally, the practice did not have a well-established policy for following up with patients who missed or cancelled appointments. Thus, when the patient scheduled and cancelled three more appointments, she received no communication that stressed the importance of returning for additional testing/care.

Behavioral Issues

Patient and provider/staff behavior can influence the dynamic of medical and dental encounters and contribute to malpractice allegations. Although

Better patient involvement strategies might have triggered the patient to contact the practice when she didn’t hear from them…

Clinical Systems and Administrative Risk Tipsn Evaluate office processes for tracking test results, patient follow-up activities, and

referrals and consults. Identification of gaps in these processes should prompt proactive measures to implement safeguards.

n Establish appropriate timeframes for following up with patients about test results, lab work, missed/cancelled appointments, etc. Develop a mechanism that will ensure the immediate reporting and follow-up of critical test results.

n Assign responsibility for follow-up activities.

n Verify patient identifiers (e.g., patient name, record number, birth date) as part of information management processes.

n Ensure that staff and provider training is consistent with roles and responsibilities, and ensure appropriate training on new or upgraded systems.

n Emphasize the importance of test and consulting/referral tracking processes.

n Evaluate staff and provider competency with clinical systems and ensure appropriate supervision.

n Include review of clinical systems and administrative functions as part of your practice’s quality improvement initiatives.

not as prevalent as other contributing factors, behavioral issues are present in

approximately 5–10 percent of diagnosis-related claims (based on MedPro claims data) and represent a persistent risk.

Generally, behavioral issues can occur with patients or with members of the healthcare team. However,

when looking at diagnosis-related claims, the majority of behavioral issues are associated with patients, as shown in Figure 2.

Problematic patient behavior can erode the doctor–patient relationship and increase liability risks. Within diagnosis-related claims, three categories related to patient behavior rise to the top: patient noncompliance with treatment, patient noncompliance with follow-up calls and appointments, and seeking another provider due to dissatisfaction (see Figure 3 on pg. 30).

Problematic patient behavior can erode the doctor–patient relationship and increase liability risks.

Figure 2. Diagnosis-Related Claims: Focus on Behavior — Patient and Provider/Staff Factors Source: Medical Protective coded claims data, 2001–2010

Patient Factors Provider/Staff Factors

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Of the three categories shown in Figure 3, patient noncompliance (with both treatment regimens and with follow-up calls and appointments) is the most prevalent issue, and it can contribute to poor outcomes even if harm occurred as a result of the provider’s actions. Consider the following scenario:

A 72-year-old female with a history of Type 1 diabetes mellitus presented to her doctor with complaints of swelling in her right groin area. Five days earlier, the patient had self-inserted a needle into the area to drain it. The area was noted as red and warm, with a tender, grape-sized abscess.

The doctor incised the abscess, placed a small rubber drain, and obtained a culture (which was negative). He prescribed an oral antibiotic and advised the patient that additional surgery to fully open and drain the abscess was recommended. However, the doctor did not document this discussion in the patient’s record, and he did not initiate a formal consultation with a surgeon.

Behavior-Related Risk Tips

n Establish a policy defining the basic rights and responsibilities of each patient. This provides a foundation on which to build an effective provider–patient relationship. Display or make this information available to all patients.

n Provide noncompliant patients with education about their treatment plans both verbally and in writing — especially if the patient has serious health problems.

n If a patient has financial, physical, or emotional limitations that lead to noncompliance, determine whether any community services are available to assist the patient and improve compliance.

n Document all instances of noncompliance as they occur, as well any education provided to the patient and/or family regarding the consequences of not following the treatment regimen. When documenting noncompliance, include statements from the patient and/or family (in quotes) and objective information obtained through doctor–patient encounters.

n Consider using behavior contracts to address problematic patient behaviors in an effort to preserve the provider–patient relationship (or to support the process of terminating the provider–patient relationship). Both the provider and patient should sign the contract.

n Document missed or cancelled appointments by noting either “patient no-show” or “cancelled” in the patient’s record. Do not delete original appointment entries, as the appointment log may become a valuable tool if you have to demonstrate a patient’s continued noncompliance with appointments.

n After several missed appointments, consider sending the patient a certified letter stressing the importance of keeping the appointments and complying with the treatment plan.

n Have substance use/abuse issues;

n Are frequent fliers with a history of multiple diagnostic tests;

n Lie or are rude or demanding; or

n Have repetitive and/or varying complaints without clear clinical significance.

Although behavioral issues can be difficult to address due to their sensitive nature, healthcare providers and staff members can work to effectively manage patient behavior by setting clear expectations and boundaries, establishing limitations, and thoroughly documenting noncompliant and disruptive behaviors.

ConclusionVarious factors, occurring alone or in combination, can contribute to diagnostic errors. Clinical judgment and communication are two of the top concerns in diagnosis-related claims, but other factors — such as documentation, clinical system failures/administrative issues, and behavioral problems — also represent persistent areas of risk. Although eliminating risk entirely is unrealistic, proactive measures to establish safeguards, reinforce policies and procedures, and evaluate areas of weakness can help medical and dental practices strengthen patient safety initiatives and potentially limit liability exposure.

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The patient decided to forego the additional surgery, but returned to the doctor’s office 4 days later. At that time, the doctor readjusted the drain. He noted that the area was still red and swollen; a second culture was negative (although it was later alleged that the culture was not deep enough). The doctor again advised the patient that further surgical drainage was needed, but he again failed to document the advice. Two days after the patient’s second appointment, she was admitted to the hospital and diagnosed with right leg

necrotizing fasciitis. She required an amputation of the right leg at the hip, and she underwent debridement multiple times and suffered extensive tissue loss.

Although a number of missteps in this case can be attributed to the provider — such as inadequate patient assessment, failure to obtain a consult, and insufficient documentation — the patient’s noncompliance with the doctor’s recommendation for additional surgery very likely contributed to her poor outcome. Further, as this case and the case on page 25 illustrate, behavioral issues are very closely related to other areas of risk, and these issues can compound to produce more serious outcomes. Further, noncompliance and other problematic patient behaviors — such as unrealistic demands and expectations, hostility, rudeness, disruptive actions, etc. — might not always be obvious from the outset; however, some red flags for behavioral issues may include patients who:

n Have unrecognized or untreated psychiatric disorders;

Noncompliance w/Tx Regimen

Seek Other Provider Due to Dissatisfaction

45%

40%

35%

30%

25%

20%

15%

10%

5%

0%

Figure 3. Diagnosis-Related Claims: Focus on Behavior — Top Behavioral Issues Source: Medical Protective coded claims data, 2001–2010

% o

f dia

gnos

is-r

elat

ed c

laim

s in

volv

ing

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as

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ctor

Noncompliance w/Follow-Up

Call/Appt.

PHYSICIANS AND DENTISTS

45%

39%

11%

(Continued from page 5)

Within these broad areas of concern are more specific issues that may lead to diagnostic mishaps or failures. Examples of such issues include:

n Vulnerabilities in clinical workflow processes and organizational policies;

n Cognitive failures or biases;

n Breakdowns in interaction between systems and providers; and

n Issues with information synthesis.

Claims may involve multiple issues and contributing factors, as well as more than one provider. In fact, many diagnosis-related claims are multifactorial.10 Hence, in a 2013 research article about the type and origins of diagnostic errors, the authors explain that strategies to address diagnostic errors should “account for their common contributory factors and not just attempt to augment knowledge or clinical skills related to specific diseases because such interventions may not generalize across diseases or care settings.”11

From a risk management perspective, contributing factors are important because they might be amenable to risk-reduction strategies. Identifying the factors that drive claims and taking corrective actions to address them is a key risk management focus.

ConclusionDiagnostic errors represent a frequent, serious, and costly risk. Although not all diagnostic errors result in adverse events, many do — creating legitimate patient safety and liability concerns.

The subsequent articles that appear in this issue of Protector will delve into further detail about, and analysis of, the factors that contribute to diagnostic errors, and they will present a number of strategies to help doctors and their staffs assess and address risks surrounding the diagnostic process. Endnotes 1 McDonald, K. M., Bryce, C. L., & Graber, M. L. (2013,

October). The patient is in: Patient involvement strategies for diagnostic error mitigation. BMJ Quality and Safety, 22(Suppl 2), ii33–39.

2 Ely, J. W., Graber, M. L., & Crosskerry, P. (2011, March). Checklists to reduce diagnostic errors. Academic Medicine, 86(3), 307–313.

3 Crosskerry, P. (2013, June). From mindless to mindful practice — cognitive bias and clinical decision making. New England Journal of Medicine, 368(26), 2445–2448.

4 Ely, et al., Checklists to reduce diagnostic errors.

5 Zwaan, L., Schiff, G. D., & Singh, H. (2013, August). Advancing the research agenda. BMJ Quality and Safety, 22(Suppl 2), ii52–57; Graber, M. L., Wachter, R. M., & Cassel, C. K. (2012). Bringing diagnosis into the quality and safety equations. Journal of the American Medical Association, 308(12), 1211–1212.

6 Clark, C. (2013, November 7). Diagnostic error detection comes into focus. HealthLeaders Media. Retrieved from http://www.healthleadersmedia.com/page-1/QUA-298106/Diagnostic-Error-Detection-Comes-Into-Focus

7 National Practitioner Data Bank Public Use File, Dec. 2013.

8 Brown, T. (2013, July 18). Missed diagnoses may trigger primary care malpractice claims. Medscape. Retrieved from http://www.medscape.com/viewarticle/808132

9 National Practitioner Data Bank, Public Use File, December 2013.

10 Wallace, E., Lowry, J., Smith, S. M., & Fahey, T. (2013, July). The epidemiology of malpractice claims in primary care: A systematic review. BMJ Open, 3(7), 1–8.

11 Singh, H., Giardina, T. D., Meyer, A. N., Forjuoh, S. M., Reis, M. D., & Thomas, E. J. (2013, March 25). Types and origins of diagnostic errors in primary care settings. Journal of the American Medical Association Internal Medicine, 173(6), 418–425.

Diagnostic Errors: A Closer Look at a Persistent Risk

32 Protector n Summer 2014

PROTECTOR IS GETTING A MODERN MAKEOVER!

For more than 100 years, Medical Protective has provided insureds with Protector — the national’s oldest and most comprehensive risk management resource. Although the need and demand for risk management information has not diminished, MedPro

recognizes that changes have occurred in the ways in which healthcare providers communicate and prefer to receive information.

To meet our insureds’ evolving needs, and to continue to provide exemplary products and services, MedPro’s Clinical Risk Management Department is

overhauling Protector to create a more flexible, engaging, and convenient way to communicate risk management content and news.

Beginning in January 2015, Protector will shift from a continuing education-based journal that is published three times a year to a more frequent and dynamic

information feed delivered through social media. This new approach will encompass a large breadth of risk resources — such as articles, tools, announcements, links,

and more — disseminated in an accessible, at-a-glance format that is designed with you, our valued customer, in mind.

More details about this change will be communicated in the coming months. We hope you will enjoy the final two journal-based issues of Protector, and we look

forward to seeing you on social media in 2015!

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