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WaPo article on bungled ED diagnosis and aftermath

  • 1.  WaPo article on bungled ED diagnosis and aftermath

    Posted 10-04-2020 23:44

    This story is pretty powerful. A doctor receives a misdiagnosis, which he later catches and corrects. He contacts the hospital where the misdiagnosis occurred, offering to help them improve. But he's rebuffed. https://www.washingtonpost.com/health/hospital-misdiagnosis-mistakes-ignored/2020/10/02/7bac2d10-f851-11ea-be57-d00bb9bc632d_story.html

     

    ..........................................

    Brian R. Jackson, MD, MS

    Assoc. Professor of Pathology (Clinical), University of Utah

    Medical Director of Support Svcs, IT and Business Development, ARUP Laboratories

     

    500 Chipeta Way, Mail Code 933

    Salt Lake City, Utah 84108-1221

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  • 2.  RE: WaPo article on bungled ED diagnosis and aftermath

    Posted 10-05-2020 07:15
    Thank you for sharing
    Karen

    Karen P. Zimmer, MD, MPH
    Health IT, patient safety, and quality consulting
    Associate Professor, Jefferson University
    Instructor, Jefferson School of Population Health

    Sent from my iPhone
    Please excuse all the typos!




  • 3.  RE: WaPo article on bungled ED diagnosis and aftermath

    Posted 10-05-2020 08:55
    This is a good illustration of an all too common problem in healthcare. I personally had experience with a missed or incorrect diagnosis in 2 family members and each time trying, respectfully, to call attention to it so learning and correction could occur, those efforts were not welcome. Instead, there was a defensiveness as though sharing the information was accusatory, which it was not intended to be.




  • 4.  RE: WaPo article on bungled ED diagnosis and aftermath

    Posted 10-05-2020 09:05
    The scenario described in This story should be a Joint Commission "NEVER" event and subject to sanction.

    ------------------------------
    David L Meyers, MD, MBe, FACEP
    Board Member,
    Society to Improve Diagnosis in Medicine
    Sinai Hospital of Baltimore
    Berman Institute of Bioethics
    ------------------------------



  • 5.  RE: WaPo article on bungled ED diagnosis and aftermath

    Posted 10-05-2020 09:22
    Remember the pressures faced by the practitioners; we are carefully instructed to obfuscate, don't talk, deny.
    If we talk, we will not be covered by the malpractice insurer.
    This is made abundantly clear to those of us on the front lines and is spelled out in contracts; I have my own theories as to why.
    So help us change that and you;'ll see a lot change!!
    Until then, let's work on achievable goals.

    tom benzoni






  • 6.  RE: WaPo article on bungled ED diagnosis and aftermath

    Posted 10-05-2020 10:11

    The whole thing is disturbingly sad. A couple of questions for the risk/ malpractice experts on this list-serve.

     

    Could you inform on the "will not be covered by the malpractice insurer" if you talk? How does the "obfuscation, don't talk, deny, defer to patient experience and administrators to deal with the issue" align with the apology and disclosure movement that risk management and malpractice carriers seem to support?

     

    Vinita. 

     

     






  • 7.  RE: WaPo article on bungled ED diagnosis and aftermath

    Posted 10-05-2020 11:49
    A very similar situation occurred with me. I was becoming increasingly short of breath with O2 sat's of 88-90%, and presented at my local ED via ambulance because I was passing out. I was placed in a back room, with a non-functional monitoring system and waited over 30 minutes to be seen by the physician. When I questioned why I would be placed in a room without central monitoring and out of line of sight from the nurses station, I was told that no other beds were available. The doctor examined me and diagnosed me with pneumonia. I asked if she included PE in her differential, and she didn't think that was likely. They put me on oxygen for 30 minutes or so, got me a script for antibiotics and discharged me around 3 am. I took a cab home (I lived alone at the time) and slept downstairs on my sofa, since I was unable to climb the stairs. The next day, I had a co-worker drive me to the hospital I was the lab manager at and presented to their ED. I was still dyspneic and hypoxic and when I mentioned to the ED doc that I thought a D-dimer and spiral CT w/ contrast was needed to r/o PE, he ordered both. Low and behold, I was diagnosed with severe bi-lateral PE and evacuated to a higher level of care at another hospital, and admitted to the ICU. 
    A few weeks after discharge from that facility, I called the first hospital and asked to speak with the ED director. I wanted to discuss the missed diagnosis and, more importantly, what I felt was a poor decision to place a patient with severe breathing problems in a remote room with no central monitoring. The director called back once, left a message, and didn't return my subsequent calls. I chose a different route at that time, calling the CEO of the hospital, who I was friendly with, and presented my case that way. I chose never to go back to that facility, even though it was less than 5 minutes away, and always went to my hospital, which was almost 20 minutes away.
    Thanks,
    Joe Keary





  • 8.  RE: WaPo article on bungled ED diagnosis and aftermath

    Posted 10-05-2020 11:58
    All good stories and great learning opportunities, if we would only take them.The basic message from David Newman-Toker et al, published in Diagnosis last year, and from other studies. is that the most significant diagnostic failures result from error in clinical judgment i.e. how clinicians think and not what they know.
    The imperative to understand cognitive failure continues and especially the impact of bias on our clinical judgment.
    Pat Croskerry





  • 9.  RE: WaPo article on bungled ED diagnosis and aftermath

    Posted 10-05-2020 13:08
    Pat Kroskerry,

    Would knowing the top errors made in each specialty help?

    Or maybe the top errors referred to each specialist.

    Could a study be undertaken to elicit such information?

    And the best way to do this? 

    Who to sponsor?

    Rob Bell, M.D.







  • 10.  RE: WaPo article on bungled ED diagnosis and aftermath

    Posted 10-05-2020 13:27
    Thank you for sharing such an important article, Dr. Jackson.  Here's how I just described this situation on social media plus some input for this group alone.

    This article written by a #neurologist whose #emergency care was inept and inadequate illustrates the potential problems that every #patient faces when they engage with the #healthcare system. Had this patient been like the rest of us, and not a top neurologist, he would currently be a quadriplegic or dead. The disappointing response that he received from the hospital system makes us want to throw up our hands in despair. But we can't. As patients, we need to protect ourselves from potential harm by being educated and engaged in our own healthcare. Please read my Dx IQ columns about how to do that at https://www.improvediagnosis.org/dxiq-column/ before your next appointment. #PatientEducation #PatientEmpowerment #PatientEngagement #PatientSafety

    But the issues are so much broader than those caused by one incompetent emergency care specialist and a hospital administration that makes excuses for him. The very systems that are designed to protect us, hurt patients. For example, I just had a follow-up telehealth appointment after receiving an epidural injection for ongoing treatment of my lower spine. Not a big deal, it's something that I routinely do three or four times a year. However, in preparing for this telehealth visit, I went through my portal - as required - where I noticed that my changes in prescriptions were still waiting to be approved, over nine months after I had made them. When the fellow pre-interviewed me on the video call, he asked me about my current prescriptions and mentioned one that I had removed from the portal over a year ago because I had an anaphylactic reaction to it. I said to him I have done my job as a patient and updated the medications list before every appointment, and when I checked it this morning it was still inaccurate. Why is it so out of date? And his answer angered me because he said, "I have no idea how to update the portal with your input." Then he blathered on for a while about how the hospital system has just updated their system. I reminded him that my edits have been made over nine months ago, not one week ago. 

    The attending got on the call and told me that the system had just been updated and it had been re-designed by one of their doctors to make it more efficient. I asked him whether or not a patient representative have been on the design team and he was surprised at the question. Nothing substantial will improve for patients until knowledgeable patient representatives are included in major decisions, policy changes, clinical trial design,  drug trial design, research studies, even on medical review boards who routinely allow incompetent, sometimes criminal, physicians, and surgeons to continue practicing. 

    The people on this listserve are the good guys, the ones who care, the ones who want to make things better. You have a responsibility to ensure that nothing is studied or changed without knowledgeable and competent patient representatives as part of the decision making process. It is a small change in thinking that will have big positive impact.

    Best regards,
    Helene 







  • 11.  RE: WaPo article on bungled ED diagnosis and aftermath

    Posted 10-05-2020 14:39
    Rob: I'm assuming as this was addressed to me that the questions were specifically about cognitive error.
    I agree that It might help some in each specialty if they knew their top errors. Historically, there has been some effort already when different specialties have identified their own pitfalls and develop caveats in their discipline-specific decision making e.g. all that wheezes is not asthma in medicine, always examine the joint above and below in orthopedics, always rule out an underlying medical condition in a diagnosis of conversion disorder in psychiatry, rule out worst-case scenario in emergency medicine, and many others.
    Other than that, I'm not aware of any work developing discipline-specific vulnerabilities to cognitive error. As far as my own specialty goes we have recently published a series of 42 cases in emergency medicine in which we attempted to identify the top cognitive errors in cases associated with diagnostic failure. The general findings were:

    • Knowledge-based errors (a sub-class of cognitive error) were relatively uncommon - only a handful
    • Error producing conditions (that mostly had an impact on cognition) - such as fatigue, sleep deprivation, distraction, increased cognitive load, increased stress, rapid task-switching, and others – 43 total.
    • Cognitive and affective biases (considered by cognitive scientists to represent the most significant challenge to decision making) - 230.

    Given that emergency medicine is the specialty of non-specializing, I would expect that this breakdown might hold for others of comparable undifferentiated presentations (internal medicine, family medicine), but not for the pattern recognition specialties (dermatology, radiology, anatomic pathology).
    For the record, we also developed the top cognitive biases that occur in emergency medicine (we found 25 for typical EM cases) - again, I would consider this list to hold for internal medicine and family practice, but the pattern recognition specialties would likely see a smaller, more confined list e.g. mostly search satisficing, premature closure, inattentional blindness and others.

    Pat .   
       
      





  • 12.  RE: WaPo article on bungled ED diagnosis and aftermath

    Posted 10-05-2020 16:18
    Michael Bruno has some interesting thoughts on "Error and Uncertainty in Diagnostic Radiology"
    I would hope that he would weigh in.

    How much of what we saw in these two examples related to system problems or "arrogance".  One time in hospital, a hospitalist examined (and billed for) examining my wife's heart and lungs through her gown.  When I suggested that I had taught CV/Pulmonary physical exam for several years and that I thought auscultation through clothing wasn't appropriate, the young man replied, "I have very good ears."  (Sigh)






  • 13.  RE: WaPo article on bungled ED diagnosis and aftermath

    Posted 10-05-2020 17:18

     

     

    October 5, 2020

    4:33 PM

     

    The medical field is no different than other science related careers; the individual cannot posses all the working knowledge they will need in facing crisis with patients.  As many of you have pointed out, it requires the clinician to exercise clear thinking and decision making.  One of the choices is always to question one's own judgement and seek supportive resources.

     

    All of the world renown experts I have known in my lifetime  - everyone to the last man continually questioned their own thinking.

     

    The "system" often drives in the direction of quick answers and available treatment; but an expert is never satisfied with this shortcut.  So, in the case of the Washington Post article, the patient was the "expert" that pursued to the necessary solution.  In the many cases where the patient is not capable of going the distance, the care team needs to carry this burden.

     

    Despite all of the system issues that throw up roadblocks, the end result should be the care team's dedication to meet the patients expectation for appropriate treatment.  This is the definition of Quality of medical services.

     

    Although it usually is an individual that carries the blame when a situation goes bad, it is also the education system (teaching students to know the "right" answer, as opposed to knowing a thinking process), the facility expectations and culture.

     

    Critical Thinking is both a skill and an art.  Help your colleagues and their patients by encouraging them to improve their toolset with this as the number one priority.

     

       Nelson Toussaint

     

    TAMARAC LLC

    860-844-0199

    ntoussaint@tamarac.com

     






  • 14.  RE: WaPo article on bungled ED diagnosis and aftermath

    Posted 10-05-2020 20:29
    Dear Nelson Toussaint,

    As I have mentioned in posts, Docs do not ask enough questions, or even answer questions. And as you suggest, questions to one's self.

    Why i complex.

    How does that get fixed in diagnosis.

    Also, many of our support tests are inaccurate.

    We do not even know the accuracy of a stethoscope in different specialties, experience, and hearing losses.  

    And a blood pressure measurement is hardly ever done as recommended. Does it matter?

    Rob Bell, .









  • 15.  RE: WaPo article on bungled ED diagnosis and aftermath

    Posted 10-05-2020 13:28

    If one takes the situativity approach seriously, (see most recent issue of Diagnosis), the phrase "the most significant diagnostic failures result from error in clinical judgment i.e. how clinicians think and not what they know" does not adequately address the problem. In fact, a lot of the failure in the example cited could be attributed to deficiencies in skills, before the examiners even got to the knowing and thinking parts!

    Once we get the skills problem solved (if we can), the correct statement IMHO is "the most significant diagnostic failures result from errors in clinical judgment, i.e., how clinicians think in the settings in which the clinical/diagnostic decisions are made." We focus too much on fixing the individual's thinking defects while ignoring the conditions in which medicine is practiced and our diagnoses are made. The NAM report made that point 5 years ago as did To Err Is Human 20 years ago. We might be better off trying to figure out how to make it easier for clinicians to the right thing rather than the wrong and fix that. "It's (mostly) the systems!"   



    ------------------------------
    David L Meyers, MD, MBe, FACEP
    Board Member,
    Society to Improve Diagnosis in Medicine
    Sinai Hospital of Baltimore
    Berman Institute of Bioethics
    ------------------------------



  • 16.  RE: WaPo article on bungled ED diagnosis and aftermath

    Posted 10-05-2020 17:28
    There are any number of ways to parse the WaPo article, many of which have been articulated here. I have one framing to add and then a comment about whether clinical judgment failures are disproportionately about cognitive or affective biases (which I don't think the available evidence necessarily supports), as opposed to failures of expertise (by which I mean elaborated symptom/disease knowledge and skills that can be applied efficiently and effectively in clinical context, using the parlance of educators ---  well-honed, well-calibrated, highly-accurate system 1 reasoning, using the parlance of dual-process theory):

    1. THE BIG THREE: Rather than focusing on causes, you could also look at this as a near miss for a disease we routinely miss --- spinal abscess... one of the top 5 causes of harm from infection (PMID: 31535832), despite being a rare disorder... because it is missed 65% of the time (PMID: 32412440). If we set up protocols that reduced errors by 30% for just 15 high-risk diseases, we could prevent about 100,000 patients suffering death/disability each year in the US. Why are we arguing about the causes instead of fixing the problems in the disease contexts and clinical settings where we know they occur, leading to harm?

    2. KNOWLEDGE, EXPERTISE, and JUDGMENT: I think the jury is still out on how often diagnostic errors are due to knowledge gaps. Perhaps, as suggested by Pat Croskerry earlier, relatively few diagnostic errors can be attributed solely to simple book knowledge deficits (in the sense of MCQ exams)... though others probably disagree (PMID: 25176155), and there should be some interesting new data on this in 2021. Certainly for diagnosing dizziness, knowledge gaps are rampant and demonstrable even using epidemiologic health outcomes data (e.g., that CT scans are nearly useless to "rule out" ischemic stroke in the ED PMID: 17258669; yet many ED physicians rely on them to do so PMID: 17976351... leading to a discharge post negative CT scan in the ED among dizzy patients actually being a 2.3-fold risk factor for suffering a stroke hospitalization within a matter of days PMID: 25477217 --- in other words, the ED docs correctly risk stratified the patients with respect to stroke to get the CT in the first place, but were falsely reassured by the negative result PMID: 26231272). But setting book knowledge aside, there is a lot to commend the theory that the final common pathway for "clinical judgment failures" is not bias, per se, but lack of expertise (PMID: 26980778), which, in turn, is due to a lack of "deliberate practice" in diagnosis in the formal sense of the term, as used by Ericsson (PMID: 18778378), which, itself (in addition to sustained attention to self-improvement and the right training materials) requires prompt and accurate feedback, which we rarely get in routine clinical practice (PMID: 30386846). Certainly in my experience as a neurologist, where I have seen huge numbers of diagnostic errors made in frontline care settings with neurological diseases, almost every one could be attributed to failures of clinical expertise. In my opinion, cognitive bias is what thrives in the void of expertise --- when system 1 remains miscalibrated, we rely on whatever faulty heuristics live nearby.

    David

    ------------------------------
    David Newman-Toker
    Johns Hopkins University
    ------------------------------



  • 17.  RE: WaPo article on bungled ED diagnosis and aftermath

    Posted 10-05-2020 21:13

    Agree David.  Knowledge and expertise of course plays a significant role. There is no way a generalist can be expected to memorize and have the knowledge and ability of the expert.   Research shows in the US that 65% of skin presentations are seen by non-dermatologists  such as emergency physicians, primary care and urgent care.  In the UK, there are roughly 500 dermatologists for 60 million people.  In some countries in Africa there are roughly 1 dermatologist for a million people.  Non-dermatologists therefore must diagnose and care for skin presentations yet they have profound knowledge gaps in knowing and recognizing the diagnostic clues found in the physical exam of the skin.  Dermatologists see these mistakes made by generalists daily.  The lack of feedback loops means that the primary care and emergency clinicians frequently do not hear what they missed.   We need to support primary care and all generalists with tools as they have not seen enough cases and lack the knowledge necessary to recognize the patterns.   In this NYT story,  we contributed images to highlight how gaps in diagnosing from skin of color further compounds the problem.  https://www.nytimes.com/2020/08/30/health/skin-diseases-black-hispanic.html  I would argue that most generalists would not be able to recognize these patterns in skin of color. 

     

    Best

    Art

    Art Papier

    CEO VisualDx

    Associate Professor of Dermatology and Medical Informatics

    University of Rochester

     






  • 18.  RE: WaPo article on bungled ED diagnosis and aftermath

    Posted 10-07-2020 12:14

    David Newman-Toker
    There are any number of ways to parse the WaPo article, many of which have been articulated here. I have one framing to add and then a comment about whether clinical judgment failures are disproportionately about cognitive or affective biases (which I don't think the available evidence necessarily supports), as opposed to failures of expertise (by which I mean elaborated symptom/disease knowledge and skills that can be applied efficiently and effectively in clinical context, using the parlance of educators ---  well-honed, well-calibrated, highly-accurate system 1 reasoning, using the parlance of dual-process theory):

    It is difficult to accept that the available evidence doesn't support the impact of biases on clinical decision making. Biases are now shown to exert impact in pretty much every human endeavour that involves decision making. It would be truly remarkable if medical decision makers were not affected in the same way as other people – is there anything about us that makes us immune? Thousands of papers have been published on this, including  in every discipline of medicine.

    In the parlance of educators, highly accurate System 1 reasoning doesn't exist.  Reasoning is a deliberate cognitive process, whereas System 1 is only capable of autonomous reflexive responses. As cognitive scientists have shown, System 1 can be highly trained to deliver good decision making, but not reasoning. Reasoning is a deliberate cognitive process that occurs in System 2.

    1. THE BIG THREE: Rather than focusing on causes, you could also look at this as a near miss for a disease we routinely miss --- spinal abscess... one of the top 5 causes of harm from infection (PMID: 31535832), despite being a rare disorder... because it is missed 65% of the time (PMID: 32412440). If we set up protocols that reduced errors by 30% for just 15 high-risk diseases, we could prevent about 100,000 patients suffering death/disability each year in the US. Why are we arguing about the causes instead of fixing the problems in the disease contexts and clinical settings where we know they occur, leading to harm?

    The reason for focusing on causes is that it provides a general tool we can all use to monitor our decision making – to try to get away with avoiding considerations of cause is counter-scientific. It is difficult to imagine a world where we say 'some people think they understand why we make these errors but we are not interested in their explanations'. As ethicists have pointed out, in this area in particular, If we know the cause of something there is an ethical imperative to understand it and use it.

    Agreed that we can (and should) develop strategies to avoid top causes of diagnostic error wherever they are known, but protocols are largely useless if you don't recognize when they need to be used e.g pulmonary embolus is missed about 50% of the time on initial presentation. It is not because we don't know the pathophysiology of thromboembolism in excruciating detail, we just don't think of it. Shouldn't we be trying to understand why we don't think of something e.g. what are the reasons for getting anchored on some other possibility? In a recent study of clinical cases we found anchoring to be the most prevalent cognitive bias – shouldn't we try to understand why decision-makers anchor and how they might avoid it when it is potentially harmful? Understanding the basis of anchoring helps us in all diagnoses not just selected ones.

    It should be possible to study the common biases in every discipline and provide appropriate training. It seems likely that the reduced numbers of diagnostic failure that are seen in the pattern recognition specialties are due to exposure to fewer biases.  

    2. KNOWLEDGE, EXPERTISE, and JUDGMENT: I think the jury is still out on how often diagnostic errors are due to knowledge gaps. Perhaps, as suggested by Pat Croskerry earlier, relatively few diagnostic errors can be attributed solely to simple book knowledge deficits (in the sense of MCQ exams)... though others probably disagree (PMID: 25176155), and there should be some interesting new data on this in 2021. Certainly for diagnosing dizziness, knowledge gaps are rampant and demonstrable even using epidemiologic health outcomes data (e.g., that CT scans are nearly useless to "rule out" ischemic stroke in the ED PMID: 17258669; yet many ED physicians rely on them to do so PMID: 17976351... leading to a discharge post negative CT scan in the ED among dizzy patients actually being a 2.3-fold risk factor for suffering a stroke hospitalization within a matter of days PMID: 25477217 --- in other words, the ED docs correctly risk stratified the patients with respect to stroke to get the CT in the first place, but were falsely reassured by the negative result PMID: 26231272). But setting book knowledge aside, there is a lot to commend the theory that the final common pathway for "clinical judgment failures" is not bias, per se, but lack of expertise (PMID: 26980778), which, in turn, is due to a lack of "deliberate practice" in diagnosis in the formal sense of the term, as used by Ericsson (PMID: 18778378), which, itself (in addition to sustained attention to self-improvement and the right training materials) requires prompt and accurate feedback, which we rarely get in routine clinical practice (PMID: 30386846). Certainly in my experience as a neurologist, where I have seen huge numbers of diagnostic errors made in frontline care settings with neurological diseases, almost every one could be attributed to failures of clinical expertise. In my opinion, cognitive bias is what thrives in the void of expertise --- when system 1 remains miscalibrated, we rely on whatever faulty heuristics live nearby.

    I cannot agree that the jury is out on the role of knowledge gaps in diagnostic error. Certainly, they do occur in select cases and it is not difficult to pick a few examples, but in the overall scheme knowledge deficits are few. Several studies have shown this.  As I noted earlier in this thread, in our recent book The Cognitive Autopsy which reviewed in detail over 40 clinical cases, we found a very wide range of clinical diagnoses (42 in all) and probably less than 6 demonstrated knowledge deficits. Further, none of these proved consequential to the diagnosis. In contrast, cognitive biases, defined according to standard descriptions in the cognitive science literature, were found in 230 instances i.e. outnumbering knowledge deficits approximately 40 to 1. Again, this should put a focus on how we think and not so much what we know.

    Cognitive bias thrives everywhere – it can be considered a normal part of brain function. System 1 can certainly be calibrated better by experience (Hogarth made this point clearly in Educating Intuition) but experts can be just as vulnerable to bias if they don't respect its power and prevalence.

    It would be a brave person these days to claim that biases are not exquisitely influential in human decision making and not exemplified in every human endeavor. If anyone remains unconvinced take a look at two other recent books in the medical literature: the neurologist Jonathan Howard's Cognitive Errors and Diagnostic Mistakes, and the general practitioner Cym Ryle's book Risk and Reasoning in Clinical Diagnosis.  



    ------------------------------
    Pat Croskerry
    Dalhousie University
    ------------------------------



  • 19.  RE: WaPo article on bungled ED diagnosis and aftermath

    Posted 10-07-2020 13:49
    Dr Croskerry

    I appreciate your thoughtful deliberations.. and I agree with your conclusions as elaborated

    But we are still left with one unalterable question... what level of error is "acceptable" during the generation of a working/prelim dx that is used to manage a pt during the early course of their presentation???

    Eg A young healthy woman presents to ER with mild chest non-radiating discomfort of 24 hrs duration that is not debilitating; she denies cough or SOB, normal vitals are noted, mild chest tenderness is noted over rt sided ribs; otherwise normal physical exam, only med is birth control pills.

    Does pt with this presentation "need"  CT PE imaging ? (the only test to "definitively" establish the dx of PE)  ORRRRR  is reassurance and a review of future possible symptom precautions for worsening SOB Chest pain and hemodynamic symptoms a reasonable alternative??

    (one could argue that a serum d-dimer should be done and imaging performed if abnl but that doesnt take into account the low but real false neg rate of d-dimer for VTE dx or the accuracy of various d-dimer assays that exist)

    if she re-presents with a severe PE dx 24-96 hrs later, should we state that a "dx error" occurred during the first evaluation? was the initial evaluation "wrong"? did the first evaluation reflect biased or incorrect reasoning?
    (if yes, what bias or knowledge gap was present during the first evaluation?)

    I believe that most clinicians recognize that SOME harmful outcomes / adverse events occur because of biased reasoning and or incorrect thinking... BUT not ALL adverse events...

    Some adverse events are simply due to the unalterable reality that ALLLLLL diagnoses are essentially prelim/working dx UNTIL time goes by and we gather new data/info (ie. either the pt worsens or improves (staying the same being non-improvement...)

    The dx error community struggles with this central issue in my mind more than any other central issue.

    In my opinion, system one "pattern recognition" did not fail in my proposed case above.. and system two thinking would have concluded  that the post priori bayesian risk is "low enough" to be acceptable
    (but I am happy to hear further debate on this if any one wishes to chime in...)


    Respectfully
    Tom Westover MD






  • 20.  RE: WaPo article on bungled ED diagnosis and aftermath

    Posted 10-07-2020 16:53
    When I said 50% of the time PE was missed, I was referring to instances where the Dx 'wasn't thought of'. If it is considered on the differential and there is enough currently acceptable evidence to satisfy the clinician that it does not warrant further follow-up, then that seems to be a reasonable stopping point - with the usual caveats, what to watch out for etc. (We don't have the resources, and at times it is unsafe to take everything to a finite conclusion). It may have something to do with individual risk tolerance but I don't think you could say one of the classic cognitive biases was in play if it was thought through.
    After the role of systemic factors has been assessed, it appears that some adverse events are probably unavoidable. In Mark Graber's classic study, the estimate was about 7%.
    Pat. 





  • 21.  RE: WaPo article on bungled ED diagnosis and aftermath

    Posted 10-07-2020 17:31
    Pat's right. Documenting that one thought of the possibility and the reasons for stopping the workup without further testing (and I don't mean clicking that macro that pops up that often includes "ectopic pregnancy" in the differential dx of abdominal pain - in a MALE) is often enough. That will change the paradigm from "negligence" to "judgment." It's very difficult to be sued for mis-judging a situation if one's rationale is well-documented. In Dr. Horowitz's case, there was nothing that would allow one to claim it was a case of judgment. The evidence was clear and the negligence obvious. Thankfully he's doing well. That's most often not the case.

    ------------------------------
    Charles Pilcher MD FACEP
    Editor, Medical Malpractice Insights - Learning from Lawsuits
    https://madmimi.com/p/5f4487
    ------------------------------



  • 22.  RE: WaPo article on bungled ED diagnosis and aftermath

    Posted 10-07-2020 19:43
    For lung and heart symptoms in the ER how often is clotting history asked for?

    Rob Bell







  • 23.  RE: WaPo article on bungled ED diagnosis and aftermath

    Posted 10-08-2020 16:06
    Pat Kroskerry and others,

    When we move towards artificial intelligence in medicine do we think the computer programs used will eventually be able to correct for cognitive biases?

    If they can do this would/should that hasten the use AI in diagnostic medicine?

    Rob Bell, M.D.




  • 24.  RE: WaPo article on bungled ED diagnosis and aftermath

    Posted 10-09-2020 00:37
    AI may be the source of the macros that pop up on most EHR's these days, the ones that I find in the MDM section of ER charts that say: "I have considered the following diagnoses in the process of evaluating the patient and do not believe that further workup is required at this time for appendicitis, bowel infarction, mesenteric thrombosis, volvulus, intussusception, acute MI and ACS, diverticulitis, gallstones, cholecystitis, abdominal aortic aneurysm, fibroids and ectopic pregnancy." And the patient is MALE. When I see a note like this when reviewing a record for an attorney, I can no longer accept anything in the record as truth. It's all "click-tation." And the patient dies of a dissecting aortic aneurysm 4 hours after leaving the ER.

    AI may be able to lead the horse (doctor) to water, but it can't make him/her drink - especially if the horse (doctor) doesn't feel thirsty.

    Chuck Pilcher

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    Charles Pilcher MD FACEP
    Editor, Medical Malpractice Insights - Learning from Lawsuits
    https://madmimi.com/p/5f4487
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