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Decision Making in Emergency Medicine

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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Decision Making in Emergency Medicine

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

  2. 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

  3. 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

  4. 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?

  5. How many turtle doves did my true love send me on the 2nd day of Christmas?

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

  7. Which is correct? The Earth moves around the Sun The Sun moves around the Earth Both

  8. 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?

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

  10. 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?

  11. 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

  12. 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

  13. 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

  14. 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)

  15. How we thinkdeterminesHow we make decisions which determines Accuracy of diagnosis

  16. How well do we do?

  17. CRICO Risk Management Foundation Harvard Affiliated Hospitals Insurers

  18. 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.

  19. Legal outcome by critical incident CMPA Data : 347 legal actions closed 2005 - 2009 Number of patients

  20. Legal outcome by critical incident CMPA Data : 347 legal actions closed 2005 - 2009 Number of patients

  21. VMIA Risk Management and Insurance, Victoria, Australia

  22. VMIA Risk Management and Insurance, Victoria, Australia

  23. 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%)

  24. Schiff et al, Arch Int Med 2009

  25. 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

  26. Arch Intern Med 2009;169:1881-1887.

  27. 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

  28. So where are we ?

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

  30. Formal Objective Scientific Quantitative Verifiable Rigorous Informal Subjective Context dependent Qualitative Dynamic Flexible

  31. BMJ Nov 2010

  32. Dual Process Theory

  33. Type 1 and Type 2processes(dual process theory)

  34. X4 C2 C3 X3 X2 X1 C1 X4

  35. A schematic model for how the systems work together

  36. Intuition RECOGNIZED Pattern Recognition T Patient Presentation Pattern Processor Executive override Dysrationalia override Calibration Diagnosis Repetition Analytical NOT RECOGNIZED

  37. Type 1 Processes RECOGNIZED Pattern Recognition Patient Presentation Pattern Processor Executive override T Dysrationalia override Calibration Diagnosis Repetition Type 2 Processes NOT RECOGNIZED

  38. System 1 RECOGNIZED Expertise Proficiency Initial percept or problem Pattern Processor Competence Calibration Calibra Decision Advanced Beginner Novice System 2 NOT RECOGNIZED

  39. Toggle Function(Hypothesis Hopping)

  40. Type 1 Processes RECOGNIZED Pattern Recognition Patient Presentation Pattern Processor Executive override T Dysrationalia override Calibration Diagnosis Repetition Type 2 Processes NOT RECOGNIZED

  41. 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

  42. ‘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

  43. We need to know System 1 and learn how to educate intuition

  44. Application of the model in the ED

  45. More errors

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