JAMIE FOX, MDASSOC PROFESSOR

DEPT OF PEDIATRICS

DIV HOSP/EMERG MED

Cognitive Errors:How Great Clinicians Reach

Wrong Conclusions

DAVID GORDON, MDASSOC PROFESSOR

DEPT OF SURGERY

DIV EMERG MED

March 12th, 2015

Overview of Dx Errors

Dual-Process Theory

Prevention Strategies

Cognitive Biases

Medicine Trauma

Mark Graber, MD

Missed, Delayed, or Wrong Diagnosis

Hardeep Singh, MD

Missed opportunities to make a timely or correct diagnosis

James Reason, PhD

The failure of a planned action to achieve its desired goal

What is Diagnostic Error?

122,577 patients admitted to six trauma centers

Significant preventable errors in 4% of patients

5.9% preventable or potentially preventable trauma deaths

1,295 total deaths

Davis et al., Journal of Trauma, 1992

An Analysis of Errors Causing Morbidity and Mortality in a Trauma: A Guide for Quality Improvement

Phases of Care

Resus

53%

OR

26%

CC

21%

CC

50%

Resus

36%

OR

14%

Errors Preventable Deaths

Failure to appropriately evaluate abdomenMost common

Errors in neurologic resuscitation 33% resuscitative and 12% overall preventable death

Critical Careunrecognized intra-abdominal sepsis, ventilator/pulmonary management, head injury management, hemodynamic monitoring failures

Patterns of Errors Contributing to Trauma MortalityLessons Learned from 2594 Deaths

1996-200444, 401 trauma patient admissions 5.8 % deaths2.5% deaths had contributing errors

Gruen et al., Annals of Surgery, 2006

Major Patterns of Error Contributing to Mortality

Hemorrhage Control

Abdomen/Pelvic (16%)

Intrathoracic (9%)

Airway management (16%)

Inappropriate management of unstable patient (14%)

Lengthy initial operative procedure (8%)

Procedure complication (12%)

Inadequate prophylaxis (11%)

Missed or delayed diagnosis (11%)

Overresuscitation with fluids (5%)

Overview of Dx Errors

How common is diagnostic error?

DiagnosticError

Error-relatedHarm

Up to 80,000 deaths/year 10 deaths/year

1/1000 outpt encounters 1 diagnostic harm/day

US Your Hospital

Adapted from Dr. Mark Graber’s MD, FACP webinar on 12/3/13: “Preventing Diagnostic Error: Where do I start?” Sponsored by National Patient Safety Foundation

1/20 adult outpt12million adults/yr

Graber M et al. Arch Int Med. 2005;1493.

Graber M et al. Arch Int Med. 2005;1493.

0

20

40

60

80

100

120

140

160

FaultyKnowledge

Faulty DataGathering

FaultySynthesis:

Verification

FaultySynthesis:

InfoProcessing

Cognitive Errors

Overview of Dx Errors

Dual-Process Theory

Dual-Process Reasoning

Deliberate

ConsciousUnconscious

Rapid

METACOGNITI

ON

INTUITION

System 2Analytical

System 1Non-analytical

Quirk M. Intuition and Metacognition inMedical Education: Keys to DevelopingExpertise. 2006.

System 1: Intuition

NON-ANALYTIC

Relies heavily on EXPERIENCE

PatternRecognition

FAST

“Thinking without thinking” LOW

cognitive load

System 2: Metacognition

ANALYTIC

Deductive reasoning

Logical

SLOW

“Thinking about one’s own thinking”

HIGHcognitive load

System 1: Intuition

PITFALLS

Strongly influenced by

ambient conditions

Atypical presentations

Pattern mistaken for something else

System 2: Metacognition

PITFALL

SLOWIMPRACTICAL

Croskerry P. Acad Med. 2009;84:1022-1028.

DUAL PROCESS THEORY

Overview of Dx Errors

Dual-Process Theory

Cognitive Biases

Cognitive Biases

Modeled on:Croskerry P. Achieving quality in clinical decision making: cognitive strategies and detection of bias. Acad Emerg Med. 2002 Nov;9(11):1184-204.and Lucey C, Winiger D, Shim R. “Towards a More Effective Morbidity and Mortality Conference” APDIM Spring Meeting, 2004

AnchoringTendency to lock onto initial

impressions or pieces of information early in the decision-making process. Once an anchor is set, it can be difficult to move away from and new information

is interpreted around it

CourthouseDaiquiri

“Uncooperative”

Cognitive Biases

Modeled on:Croskerry P. Achieving quality in clinical decision making: cognitive strategies and detection of bias. Acad Emerg Med. 2002 Nov;9(11):1184-204.and Lucey C, Winiger D, Shim R. “Towards a More Effective Morbidity and Mortality Conference” APDIM Spring Meeting, 2004

ConfirmationTendency to look for and

weight confirming evidence to support a diagnosis

rather than evidence that refutes it

Attempted to hit nurse“Leave me alone”

Cognitive Biases

Modeled on:Croskerry P. Achieving quality in clinical decision making: cognitive strategies and detection of bias. Acad Emerg Med. 2002 Nov;9(11):1184-204.and Lucey C, Winiger D, Shim R. “Towards a More Effective Morbidity and Mortality Conference” APDIM Spring Meeting, 2004

Premature closureTendency to shut down the

decision-making process prematurely, accepting a

diagnosis before it has been fully verified

Vomiting and Uncooperative d/t

alcohol consumption

Cognitive Biases

Modeled on:Croskerry P. Achieving quality in clinical decision making: cognitive strategies and detection of bias. Acad Emerg Med. 2002 Nov;9(11):1184-204.and Lucey C, Winiger D, Shim R. “Towards a More Effective Morbidity and Mortality Conference” APDIM Spring Meeting, 2004

Diagnosis momentumOnce diagnostic labels are attached to patients they

tend to stick

He’s drunk

Cognitive Biases

Modeled on:Croskerry P. Achieving quality in clinical decision making: cognitive strategies and detection of bias. Acad Emerg Med. 2002 Nov;9(11):1184-204.and Lucey C, Winiger D, Shim R. “Towards a More Effective Morbidity and Mortality Conference” APDIM Spring Meeting, 2004

Availability HeuristicJudge things as being more

likely, or frequently occurring, if they more readily come to mind

Alcohol as opposed to head bleed as cause of

vomiting

Cognitive Biases

Modeled on:Croskerry P. Achieving quality in clinical decision making: cognitive strategies and detection of bias. Acad Emerg Med. 2002 Nov;9(11):1184-204.and Lucey C, Winiger D, Shim R. “Towards a More Effective Morbidity and Mortality Conference” APDIM Spring Meeting, 2004

Gambler’s fallacyThe belief that if a coin is

tossed ten times and is heads each time, the 11th

toss has a greater chance of being tails

“We can’t have 3 kids w/ appy in 1 shift”

Cognitive Bias

Overattachment

Alternative/

2nd Diagnosis

Inherited

Thinking

Prevalence/

Estimation

Patient

Context

Physician

Attributes

Campbell SG, Croskerry P, and Bond WF. Acad Emerg Med. 2007; 14:743-749.

CATEGORIES

Overview of Dx Errors

Dual-Process Theory

Prevention Strategies

Cognitive Biases

CHECKLISTS/PROTOCOLS

Gruen et al., Annals of Surgery, 2006

Cognitive Debiasing Strategies

Mental strategies to avoid cognitive error

Forced Thinking

THE DIAGNOSTIC TIME OUT

Forced Thinking

What else could it be?

Is there anything that doesn’t fit?

Is it possible that I have more than one problem?

• Adequacy• Are all the patient's findings

(abnormal or normal) accounted for by the diagnostic hypothesis?

Have I explained all the patient’s findings?

• Coherency• Is the diagnostic hypothesis

pathophysiologically consistent with all the clinical findings?

Is there a non-fit?

Diagnostic VerificationCriteria of Validity

Life ThreatsAdequacyConsistency/CoherencyElse (What else could it be?)

Second Problem

Unexplained Symptom(s)

Return visit

At-risk patient population

Critical condition

End of shift

When should we take a time out?

Milestones

RAPID SEQUENCE

INTUBATION FIBRINOLYTICFOR ACUTE MI

TX TIMES FOR INVASIVE

INFECTIONS

“NOT YETDIAGNOSED”

Admission Tags

CHEST PAIN – NYD

Not YetDiagnosed SHORTNESS OF

BREATH – TPD

Trying to Prevent Death

VOMITING – PD

Parental Distress

FEEDBACK LOOP

“Closing the Loop”

Patient

ED

Night Float

Team

Epidemiology

Classification

FUTUREDIRECTIONS

Challenges

Selected References

1. Berenson RA et al. “Placing Diagnosis Errors on the Policy Agenda.” 2014. http://www.urban.org/UploadedPDF/413104-Placing-Diagnosis-Errors-on-the-Policy-Agenda.pdf (Accessed July 29, 2014)

2. Berner ES and ML Graber. Overconfidence as a cause of diagnostic error in medicine. Am J Med. 2008;121:S2-S23.

3. Crandall B and RL Wears. Expanding Perspectives on Misdiagnosis. Am J Med. 2008;121:S30-33.

4. Graber ML et al. Diagnostic Error in Internal Medicine. Arch Int Med. 2005;165:1493.

5. Graber ML. Taking steps towards a safer future: measures to promote timely and accurate medical diagnosis. Am J Med. 2008;121:S43-46.

6. Schiff GD. Minimizing Diagnostic Error: The Importance of Follow-up and Feedback. Am J Med. 2008;121:S38-42.

7. Davis JW et al. An Analysis of Errors Causing Morbidity and Mortality in a Trauma System: A Guide for Quality Improvement. J Trauma 1992;32:660-666.

8. Gruen RL et al. Patterns of Errors Contributing to Trauma Mortality. Lessons Learned From 2594 Deaths. Ann Surg. 2006;244:371-380.