Clinical Decision Making and Diagnostic Error
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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

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 2nd day of Christmas?


Premise 1: All living things need waterPremise 2: Roses need waterTherefore: Roses are living thingsValid conclusion or not?


Which is correct?

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?


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

  • 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


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

  • 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 thinkdeterminesHow we make decisions

which determines

Accuracy of diagnosis


How well do we do?


CRICO Risk Management Foundation

Harvard Affiliated Hospitals Insurers


CRICO Outpatient Cases

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

CMPA Data : 347 legal actions closed 2005 - 2009

Number of patients


Legal outcome by critical incident

CMPA Data : 347 legal actions closed 2005 - 2009

Number of patients


VMIA Risk Management and Insurance, Victoria, Australia


VMIA Risk Management and Insurance, Victoria, Australia


Factors contributing to diagnostic failure

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


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.


Diagnostic Errors

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 ?


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


Formal

Objective

Scientific

Quantitative

Verifiable

Rigorous

Informal

Subjective

Context dependent

Qualitative

Dynamic

Flexible


BMJ Nov 2010


Dual Process Theory


Type 1 and Type 2processes(dual process theory)


X4

C2

C3

X3

X2

X1

C1

X4


A schematic model for how the systems work together


Intuition

RECOGNIZED

Pattern Recognition

T

Patient

Presentation

Pattern

Processor

Executive

override

Dysrationalia

override

Calibration

Diagnosis

Repetition

Analytical

NOT

RECOGNIZED


Type

1

Processes

RECOGNIZED

Pattern Recognition

Patient

Presentation

Pattern

Processor

Executive

override

T

Dysrationalia

override

Calibration

Diagnosis

Repetition

Type

2

Processes

NOT

RECOGNIZED


System

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)


Type

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

  • 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


Application of the model in the ED


More errors


How does DPT see it?

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

  • 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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