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Clinical Decision Making and Diagnostic Error Pat Croskerry MD PhD CEM/IFEM Symposium Quality and Safety in Emergency Care London, November, 15-16 2011. Decision Making in Emergency Medicine. The core feature of all human performance Key to understanding patient safety and quality

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Clinical Decision Making and Diagnostic ErrorPat Croskerry MD PhDCEM/IFEM SymposiumQuality and Safety in Emergency Care London, November, 15-16 2011


Decision making in emergency medicine
Decision Making in Emergency Medicine

The core feature of all human performance

Key to understanding patient safety and quality

We don’t really understand it

It needs our serious attention

It needs a lot of work


Eight Quick QuestionsTake a piece of paper and write down your answers to each of these 7 questionsYou have about 10 seconds for each response


On a standard London fire truck, there are 2 drivers up front, one at the rear and three additional fire-fighters. What is the total personnel required for 5 standard trucks?


How many turtle doves did my true love send me on the 2 nd day of christmas
How many turtle doves did my true love send me on the 2 front, one at the rear and three additional fire-fighters. What is the total personnel required for 5 standard trucks?nd day of Christmas?


Premise 1: All living things need water front, one at the rear and three additional fire-fighters. What is the total personnel required for 5 standard trucks?Premise 2: Roses need waterTherefore: Roses are living thingsValid conclusion or not?


Which is correct

Which is correct? front, one at the rear and three additional fire-fighters. What is the total personnel required for 5 standard trucks?

The Earth moves around the Sun

The Sun moves around the Earth

Both


A bat and a ball cost $1.10 in total. The bat costs $1.00 more than the ball. How much does the ball cost?


If it takes 5 machines 5 minutes to make 5 widgets, how long would it take 100 machines to make 100 widgets?


In a lake, there is a patch of lily pads. Every day, the patch doubles in size. If it takes 48 days for the patch to cover the entire lake, how long would it take for the patch to cover half the lake?


What is most likely a jack is an engineer b jack is a lawyer de neys glumicic 2008

In a study 1000 people were tested. Among the participants there were 5 engineers and 995 lawyers. Jack is a randomly chosen participant of this study.Jack is 36 years old. He is not married and is somewhat introverted. He likes to spend his free time reading science fiction and writing computer programs

What is most likely? a. Jack is an engineer b. Jack is a lawyer

De Neys & Glumicic, 2008


Answers
Answers there were 5 engineers and 995 lawyers. Jack is a randomly chosen participant of this study.

  • 30

  • 2

  • Invalid

  • (a) The Earth moves around the Sun

    _________________________________

    E. The ball costs 5¢ and the bat $1.05

    F. 5 minutes

    G. 47 days

    H. Jack is a lawyer


What is most likely a jack is an engineer b jack is a lawyer de neys glumicic 20081

In a study 1000 people were tested. Among the participants there were 5 engineers and 995 lawyers. Jack is a randomly chosen participant of this study.Jack is 36 years old. He is not married and is somewhat introverted. He likes to spend his free time reading science fiction and writing computer programs

What is most likely? a. Jack is an engineer b. Jack is a lawyer

De Neys & Glumicic, 2008


Cognitive reflective test
Cognitive Reflective Test there were 5 engineers and 995 lawyers. Jack is a

  • The test distinguishes intuitive from analytical processing

  • It tests the ability to resist first response that comes to mind

  • Of 3428 people tested only 17% got all 3 correct

  • 33% answered all three incorrectly

    Frederick 2002 (MIT)


How we think there were 5 engineers and 995 lawyers. Jack is a determinesHow we make decisions

which determines

Accuracy of diagnosis


How well do we do

How well do we do? there were 5 engineers and 995 lawyers. Jack is a


CRICO Risk Management Foundation there were 5 engineers and 995 lawyers. Jack is a

Harvard Affiliated Hospitals Insurers


Crico outpatient cases
CRICO Outpatient Cases there were 5 engineers and 995 lawyers. Jack is a

N=663 CRICO PL cases asserted 1/1/04-08/31/09 with a claimant type of outpatient.

Total Incurred=aggregate of expenses, reserves, and payments on open and closed cases.


Legal outcome by critical incident
Legal outcome by critical incident there were 5 engineers and 995 lawyers. Jack is a

CMPA Data : 347 legal actions closed 2005 - 2009

Number of patients


Legal outcome by critical incident1
Legal outcome by critical incident there were 5 engineers and 995 lawyers. Jack is a

CMPA Data : 347 legal actions closed 2005 - 2009

Number of patients


VMIA Risk Management and Insurance, Victoria, Australia there were 5 engineers and 995 lawyers. Jack is a


VMIA Risk Management and Insurance, Victoria, Australia there were 5 engineers and 995 lawyers. Jack is a


Factors contributing to diagnostic failure there were 5 engineers and 995 lawyers. Jack is a

No-Fault Factors Only

(7%)

System-Related

Error Only

(19%)

Both System-Related

And Cognitive

Factors

(46%)

Cognitive Error Only

(28%)


Schiff et al, Arch Int Med 2009 there were 5 engineers and 995 lawyers. Jack is a


Patient record review of the incidence, consequences, and causes of diagnostic adverse events Zwaan et al, Arch Int Med, 2010

Netherlands study of the year 2004

7926 patient records from 40 hospitals

Retrospective chart review

Diagnostic AEs 6-7% of all AEs

Mostly common diseases: PE, sepsis, MI, appendicitis

Human cognitive factors in 96% DAEs

System failures in 25% DAEs


Arch Intern Med 2009;169:1881-1887 causes of diagnostic adverse events .


Diagnostic errors
Diagnostic Errors causes of diagnostic adverse events

Are common and cause enormous harm

Make up the largest fraction of malpractice claims, and contribute to the high cost of medicine

The error rate in the perceptual specialties is near 2%; In Medicine, the error rate is probably 10- 15%

Errors happen wherever diagnoses are made: Primary Care, Emergency Department, in Hospital

The vast majority are due to the physician’s thinking


So where are we ? causes of diagnostic adverse events


It s not what we don t know it s how we think we need to know more about how we think
It’s not what we don’t know, it’s how we think. causes of diagnostic adverse events We need to know more about how we think…


Formal causes of diagnostic adverse events

Objective

Scientific

Quantitative

Verifiable

Rigorous

Informal

Subjective

Context dependent

Qualitative

Dynamic

Flexible


BMJ Nov 2010 causes of diagnostic adverse events


Dual process theory

Dual Process Theory causes of diagnostic adverse events


Type 1 and type 2 processes dual process theory
Type 1 and Type 2 causes of diagnostic adverse events processes(dual process theory)


X4 causes of diagnostic adverse events

C2

C3

X3

X2

X1

C1

X4


A schematic model for how the systems work together
A schematic model for how the systems work together causes of diagnostic adverse events


Intuition causes of diagnostic adverse events

RECOGNIZED

Pattern Recognition

T

Patient

Presentation

Pattern

Processor

Executive

override

Dysrationalia

override

Calibration

Diagnosis

Repetition

Analytical

NOT

RECOGNIZED


Type causes of diagnostic adverse events

1

Processes

RECOGNIZED

Pattern Recognition

Patient

Presentation

Pattern

Processor

Executive

override

T

Dysrationalia

override

Calibration

Diagnosis

Repetition

Type

2

Processes

NOT

RECOGNIZED


System causes of diagnostic adverse events

1

RECOGNIZED

Expertise

Proficiency

Initial

percept or problem

Pattern

Processor

Competence

Calibration

Calibra

Decision

Advanced

Beginner

Novice

System

2

NOT

RECOGNIZED


Toggle function hypothesis hopping
Toggle Function causes of diagnostic adverse events (Hypothesis Hopping)


Type causes of diagnostic adverse events

1

Processes

RECOGNIZED

Pattern Recognition

Patient

Presentation

Pattern

Processor

Executive

override

T

Dysrationalia

override

Calibration

Diagnosis

Repetition

Type

2

Processes

NOT

RECOGNIZED


6 main features of the model
6 causes of diagnostic adverse events Main Features of the Model

  • Toggle function

  • Most errors occur in System 1

  • Repetitive operations of System 2 >>> 1

  • System 2 override of System 1

  • System 1 override of System 2

  • Cognitive Miser function


‘Cognitive thought is the tip of an enormous iceberg. It is the rule of thumb among cognitive scientists that unconscious thought is 95% of all thought –

this 95% below the surface of conscious awareness shapes and structures all conscious thought’Lakoff and Johnson, 1999


We need to know system 1 and learn how to educate intuition
We need to know System 1 and learn how to educate intuition is the rule of thumb among cognitive scientists that unconscious thought is 95% of all thought –


Application of the model in the ed
Application of the model in the ED is the rule of thumb among cognitive scientists that unconscious thought is 95% of all thought –


More errors is the rule of thumb among cognitive scientists that unconscious thought is 95% of all thought –


How does dpt see it

How does DPT see it? is the rule of thumb among cognitive scientists that unconscious thought is 95% of all thought –

Cognitive overload is associated with:

Increased tendency to engage cognitive miser function

Increased time in intuitive mode

Decreased time in analytical mode

Diminished analytical monitoring of intuitive mode

Decreased toggling capacity

Compromised learning


Thinking initiatives
Thinking initiatives is the rule of thumb among cognitive scientists that unconscious thought is 95% of all thought –

  • Raise awareness of importance of decision making

  • Know operating characteristics of DPT model

  • Educate and train intuition

  • Teach the main cognitive and affective biases

  • Teach and coach debiasing techniques

  • Promote critical thinking

  • Promote use of cognitive aids

  • Raise awareness of conditions which may compromise decision making (fatigue, sleep deprivation, cognitive overload)


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