errors in the diagnostic process
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Errors in the diagnostic process. Hierarchy of Qualities in Medicine Frequency of diagnostic Errors Judgment under Uncertainty: Heuristics and Biases The Voytovich Solution. Click to View Presentation. Hierarchy of Qualties in Medicine From patient‘s point of view. Patient Satisfaction. - PowerPoint PPT PresentationTRANSCRIPT
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Errors in the diagnostic process
• Hierarchy of Qualities in Medicine
• Frequency of diagnostic Errors
• Judgment under Uncertainty: Heuristics and Biases
• The Voytovich Solution
Click to View Presentation
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Hierarchy of Qualties in MedicineFrom patient‘s point of view
Diagnostic Quality
Therapeutic Quality
Patient Satisfaction
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Hierarchy of Qualties in MedicineMedical point of view
Diagnostic Quality
Therapeutic Quality
Patient Satisfaction
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Hierarchy of Qualities in Medicine und cognitive Processes
Diagnostic Quality
Therapeutic Quality
Patient Satisfaction Skills
Rules
Knowledge
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Frequency of diagnostic Errors Follow-up Autopsy Study Medizinische Klinik USZ
1972-1982-1992-2002Lancet 2000;355:2027-31
• Random Selection of 100 patients in each year • Autopsy Rate above 90% until 1992, in the year
2002 Reduction to 53%, complete Autopsy • Classification of diagnostic Errors according to
Goldman
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Classification of diagnostic errors Goldman et al NEJM 1983:380: 1000-05
• Major diagnostic Errors– Class I: Knowledge of correct Diagnosis would have
led to Survival
– Class II: Knowledge of correct Diagnosis would not have affected Survival (too ill, no Treatment available)
• Minor diagnostic Errors– Class III: Missed Diagnosis but not cause of Death
– Class IV: Occult, clinically not diagnosable Entity of epidemiological Interest eg Gallstones
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Major Diagnostic Errors 1972-2002
0
2
4
6
8
10
12
14
16
% C
ases
Class I Class II
1972198219922002
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Minor Diagnostic Errors 1972-2002
0
5
10
15
20
25
30
35
40
% C
ases
Class III Class IV
1972198219922002
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Class I+II vs. Class III+IV
0
2
4
6
8
10
12
14
16
% C
ases
Class I Class II
1972198219922002
0
5
10
15
20
25
30
35
40
% C
ases
Class III Class IV
1972198219922002
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Correct Diagnosis 1972-2002
0
5
10
15
20
25
30
35
40
45
% C
ases
Class V Class VI
1972198219922002
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Autopsy Rate and class I Errors over time
Kaveh G et al, JAMA 2003: 289:2849-56
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Frequency of class I Errors
Klasse I Autopsie-Fehler rate
• Medizin+ IPS (USZ) 2002 2% 53%
• Med-IPS (Mayo-Clinic) 1998-2000 4% 33%
• Med-IPS (Paris) 1995-98 10.2% 53%
• Med-IPS (Leuven,Belgien) 1996 16% 93%
• 32 Spitäler in USA 1984 13% 30%
• Medizin (Boston, USA) 1984 12% 40%
Arch Int Med 2004:164;389; Mayo Clin Proc 2000:75:562; Ann Thorac Surg 1997:64:380; JAMA1987:258:339; Mayo Clin Proc. 2003;78:947-50. NEJM 1988:318;1249
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Autopsy: Gold Standard for clinical Diagnosis?
Diagnostic errors derived from Chart review
Diagnostic errors revealded by Autopsy
Without Autopsy 2/194 (1%)
With Autopsy 3/141 (2%)
Pelletier et al J Gen Intern Med 1989:4;300-03
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Autopsy: Gold standard for clinical diagnosis?
Diagnostic errors derived from Chart review
Diagnostic errors revealded by Autopsy
Without Autopsy 2/194 (1%)
With Autopsy 3/141 (2%) 19/141 (13%)
Pelletier et al J Gen Intern Med 1989:4;300-03
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• Representativness– Similarity with „typical“ examples stored in
memory
• Availability– Recent expierence, painful memory
• Adjustment and Anchoring– Stick to early hypotheses despite new
information
Judgment under Uncertainty: Heuristics and Biases
Tversky and Kahneman Science 1974:185:1124-31
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Fehlermechanismen im diagnostischen Prozess
Hypothesen-Bildung Fehler Mechanismus Diagnost. Schritt Mechanismus Fehler Falsch + Vorzeitige Schluss- Anamnese + Untersuchung Übersehen Falsch - Folgerung Falsch + dito Auslöser dito Falsch - Falsch + dito Einbettung dito Falsch -
Informationsbeschaffung, Verarbeitung und Überprüfung
Fehler Mechanismus Diagnost. Schritt Mechanismus Fehler Falsch + Annahme zu hoch Vortestwahrscheinlichkeit Annahme zu tief Falsch - Falsch + Spezifität zu tief Test (Labor, Röntgen..) Sensitivität zu tief Falsch - Falsch + Falsche Formulierung Interpretation eines Tests Falsche Formulierung Falsch- Falsch + Vorzeitige Schlussf. Kausales Modell Übersehen Falsch - Falsch + Vorzeitige Schlussf. Überprüfung Unvollständige Falsch -
Synthese
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Cognitive Mechanisms of diagnostic Errors according to A.E. Voytovich*
• Omission
• Premature Closure
• Inadequate Synthesis
• Wrong Formulations
* J Med Educ 1985:60;302-07
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Omission
• Most frequent Error
• Decreases with Experience
Consequences– Delayed or missed Diagnosis
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Premature Closure
• Independent of Experience• Correlates with Confidence (ie Overconfidence) in
Relation to the actual Case• Reflects estimated Frequency of the diagnosed
Disease Consequences
– Delayed or missed Diagnosis– Unnecessary Therapies– False Sense of Confidence if Error is not detected
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Inadequate Synthesis
• Correlates with Experience
Consequences– Unnecessary Investigations– Delayed Treatment
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Cognitive Mechanisms of diagnostic Errors according to A.E. Voytovich*
• Omission
• Premature Closure
• Inadequate Synthesis
• Wrong Formulations
* J Med Educ 1985:60;302-07
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Lancet 2000:355;2027-31
Fehlermechanismen im diagnostischen Prozess
Hypothesen-Bildung Fehler Mechanismus Diagnost. Schritt Mechanismus Fehler Falsch + Vorzeitige Schluss- Anamnese + Untersuchung Übersehen Falsch - Folgerung Falsch + dito Auslöser dito Falsch - Falsch + dito Einbettung dito Falsch -
Informationsbeschaffung, Verarbeitung und Überprüfung
Fehler Mechanismus Diagnost. Schritt Mechanismus Fehler Falsch + Annahme zu hoch Vortestwahrscheinlichkeit Annahme zu tief Falsch - Falsch + Spezifität zu tief Test (Labor, Röntgen..) Sensitivität zu tief Falsch - Falsch + Falsche Formulierung Interpretation eines Tests Falsche Formulierung Falsch- Falsch + Vorzeitige Schlussf. Kausales Modell Übersehen Falsch - Falsch + Vorzeitige Schlussf. Überprüfung Unvollständige Falsch -
Synthese
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Major Diagnostic Errors 1972-2002
0
2
4
6
8
10
12
14
16
% C
ases
Class I Class II
1972198219922002
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Sensitivity and Specificity
• 1-Sensitivity: Rate of missed Diagnoses (false negative rate)
• 1-Specificity: Rate of wrong Diagnoses (false positive rate)
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Cardiovascular Diseases Sensitivity and Specificity
69%
85%82% 82%
86%
97%
Sensitivität Spezifität50
60
70
80
90
100
1972
1982
1992
p = 0.061 p = 0.034
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Lancet 2000:355;2027-31
Fehlermechanismen im diagnostischen Prozess
Hypothesen-Bildung Fehler Mechanismus Diagnost. Schritt Mechanismus Fehler Falsch + Vorzeitige Schluss- Anamnese + Untersuchung Übersehen Falsch - Folgerung Falsch + dito Auslöser dito Falsch - Falsch + dito Einbettung dito Falsch -
Informationsbeschaffung, Verarbeitung und Überprüfung
Fehler Mechanismus Diagnost. Schritt Mechanismus Fehler Falsch + Annahme zu hoch Vortestwahrscheinlichkeit Annahme zu tief Falsch - Falsch + Spezifität zu tief Test (Labor, Röntgen..) Sensitivität zu tief Falsch - Falsch + Falsche Formulierung Interpretation eines Tests Falsche Formulierung Falsch- Falsch + Vorzeitige Schlussf. Kausales Modell Übersehen Falsch - Falsch + Vorzeitige Schlussf. Überprüfung Unvollständige Falsch -
Synthese
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Infectious Diseases Sensitivity and Specificity
25%
100%
67%
100%
86%
99%
Sensitivität Spezifität0
20
40
60
80
100
1972
1982
1992
nsp = 0.036
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Neoplastic Diseases Sensitivity and Specificity
89%
92%
88%
97%96% 96%
Sensitivität Spezifität70
75
80
85
90
95
100
1972
1982
1992
nsns
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Difficulties in learning from Experience
• Lack of Search for and use of disconforming Evidence
• Lack of outcome Information
• Use of unaided Memory for coding, storing and retrieving outcome Information
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Summary and Proposal
• Major diagnostic Errors occur despite an ever increasing repertory of diagnostic Procedures
• 85% of serious diagnostic Errors can only be detected by Autopsy
• Analysis of error mechanism can be helpful in the Discussion and Prevention of diagnostic Errors
• Minimum Autopsy rate of 30% along with a yearly Report on diagnostic Errors should be mandatory for Accreditation of medical Clinics