Safe Diagnosis 2

7/28/2019 Safe Diagnosis 2

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Safe Diagnosis

Toward a Patient Centred NHS

Presentation to the Academy of Royal Medical Colleges atthe Royal College of Surgeons 13/9/05

Nick Green Patient Public Involvement Forum Organisation

Reducing Error and Delay

http://www.ppif.org.uk


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Why am I qualified to talk about

this?

The consulting cybernetician

Decision making under uncertainty motivatescybernetics

General Management Heuristic reduces error Error Detection and Correction

Change when policy fails

Alerting, Modelling and Real Time Audit

The Body Project: to understand and catalogueall physiological and pathophysiologicalprocesses


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Background

Lethal Medical Accidents

NPSA 840 patients died

(First Annual Report 2005)

Dr Foster estimates 40,000 died

(BMJ 2004;329:369)

Rath from US data150-200,000 died

(Dr. Rath Health Foundation 151 refs)

"Compared with the transport industry, the numberof errors causing very high levels of death is

extraordinary." Roger Taylor, research director of Dr Foster


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Deaths

In 2004 514,250 died in UK and Wales

About half in hospital (BMJ. 2004 May 22;328(7450): 12351236 )

Worst case: 1 in 5 die without diagnostic ortreatment error

Best case 19 out of 20 die without diagnosticerror

Hospital death rates are reducing by 2.6% per

year (B. Jarman, The quality of care inhospitals The Journal of the Royal College ofPhysicians of London 34,Jan/Feb 2000)


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Life expectancy is increasing

Life expectancy has increased 1 year in every 4

since 1981. 1 day every 4. Why?

Are treatments improving at this rate?

ONS Life Expectancy 2004http://www.statistics.gov.uk/CCI/nugget.asp?ID=881&Pos=1&ColRank=1&Rank=374


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Causes of Death

ONS Life Expectancy 2004

http://www.statistics.gov.uk/CCI/nugget.asp?ID=881&Pos=1&ColRank=1&Rank=374


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Concurrent Interacting Processes

Virus Disease

Musculoskeletal

Blood

Lymph

Marrow

Endocrine

Ear

The Nomencleture of Disease HMSO 8th

edition


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The schoolboy howler

Patient presents anxious may havedisease with back ground rate of 1 in 1000

Diagnostic test has 95% true positive rate

Result positive

What are my chances Doc?

In fact its 50 to 1 you are ok!

One test is not enough


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Doctor Foster

Only 276,514 errors were recorded in Englishhospitals in 2004 but the National Patient Safety

Agency (NSPA) puts the true figure at closer to900,000 (Chief Medical Officer).

Approximately 25 per cent of errors occur duringsurgery

25 per cent in diagnosis or pre-care: more than200,000 in a yearhttp://home.drfoster.co.uk/news_items/1309/The Times 13 08 04.pdf

Half of all mistakes are made during wardtreatment from inadequate nutrition to incorrectdose of medication


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The Patient Model

Gold Standard:

Is the death Certificate Correct?

Diagnose Treat Outcome

10-20,000 diseases :

14-15 yes/no unambiguous questions could define

it if correctly answered. Getting these questions

correctly answered is the skill of correct diagnosis.


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Sington and Cottrell J Clin Pathol 2002;55:499502

Medical errorreporting must take necropsy data into

account Letter: BMJ2001;323:511 47% of Death Certificates correct for hospital

deaths.

Cardiovascular deaths 28% accurate

Malignant deaths 35% over diagnosed

Rate of necropsy well below recommended 10% Necropsy is not random


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Random Necropsy

If Sington and Cottrell were random then at least50% of patients are treated for the wrongdisease.

If they are worst or hard cases then 5% of

patients are treated for the wrong disease.

Challenging Cases

Prof John Senders estimates that iatrogenicdisease affects between 5% and 50% of allpatients.


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Safety critical methods

Multiple independent teams

Agreement

Self-vetoing Proof of correctness

Background error rate critical


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Improving Diagnostic Accuracy

Assume Diagnosis 75% accurate.

One doctor .75 chance of being right

Two doctors .94 of being right

Three doctors .98. Only 1 in 50 patients will

be treated for the wrong disease.

But only if independent! New history, tests and

no prompting from patient on previous findings. Bonus for diagnosticians with novel finding?


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Removing the Error from Diagnosis

-

50,000

100,000

150,000

200,000

250,000

300,000

1 2 3 4 5 6 7 8 9 10

Number of Independent Diagnoses

Errors per

million

diagnoses

Starting with 1 in 4 diagnoses wrong with one diagnostician.

Ten independent diagnoses, if they agree, will reduce diagnostic error to 1 in a

million. Culture Change! Responsibility for error shared and better feedback

for diagnosticians from colleagues

110

49

158

617

2446

9775

3,9064

15,6253

62,5002

250,0001

Errors per millionNo of Doctors

Assume no

medical break

throughs


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Even at 95% 5 Diagnosticians are

needed to get to 1 in a million error

0

50,000

100,000

150,000

200,000

250,000

300,000

1 2 3 4 5 6 7 8 9 10

75%

80%

90%

95%

110

149

3158

13617

1642446

1103209775

61001,6003,9064

1251,0008,00015,6253

2,50010,00040,00062,5002

50,000100,000200,000250,0001

95%

error

90%

error

80%

error

75%

error

Errors per millionDiagnostic

Agreement


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How to proceed?

Consultant General Physician

Decision and Risk analysis

More detail on Death Certificates: toxicburden

Multiple blind diagnosis will need major

changes to Clinical Practice. Likely savings make it feasible.

Treatment costs halved?


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Persistent Organic Pollutants

In water, food and homes

In cadavers routine at random postmortem

Synergystic toxicity: cocktail effect ofsub-toxic exposure.

Advance Directives

Religious objectors may reconsider whenthey realise they will get poorer qualitytreatment.


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Treatment errors

Wrong treatment

Side effects of right treatment

Right treatment wrongly given, incorrect

dosages- surprisingly common

CfH (NPfIT): complete real time audit of allinterventions.

Data mine of outcomes will quickly rivalPharmaceutical companies if recordingoutcomes mandatory


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Body Knowledge Mining

When CfH established

Shift NHS staff into fundamental research

2.3 in-patients per hospital doctor

1.8 nurses per patient

2 support staff per in-patient

Raise status

Elite in data capture

Majority in checking and cataloguing


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Decision

Development

Audit

Operation

Regulation

Process


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Interactions of Actors Axioms

Context

Perspective

Responsible

Respectable

Amity Agreement

Agreement-to-disagree (ATD)

Purpose

Unity not uniformity

Faith Beginnings and Ends (CT)

Eternally interacting (IA)

Similarity and Difference

Adaptation

Evolution

Generation

Kinetic (IA) Kinematic (CT)

Conservation of MeaningfulInformation Transfer bothPermissive (Ap) andImperative Application (Im)

Informational openness andOrganisational closure.

Void and Not-Void

Coherence: the product of a process


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Controlling the View of the Patient

Care Record

Independent multiple diagnoses requires

Same view of old history up to the new

incident

No view of history and tests by

competing diagnosticians

Further diagnostic encounters till riskreduced to some agreed standard level


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We need a Tricorder!

Nick Green FCybS 13/9/05 Safe Diagnosis

Contact: 020 7916 0285 [email protected]
mailto:[email protected]:[email protected]:[email protected]


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First PPIFO Conference for 2006

Speakers who have agreed to come or expressed interest include:

Alexander Harris (Malpractice Solicitors)

Dr Vernon Coleman (Decisions, Evidence and error)

Dr Barrie Cottrell (Inaccuracy of Death Certificates)

Dr Richard Fitton (NHS Connecting for Health) Dr Phil Hammond (Medical Culture)

Prof Lewis Wolpert FRS (Biology and Safer Medicine)

Sir Brian Jarman has suggested we approach the Chief MedicalOfficer on his plans for patient Safety and we think a senior DoHexecutive should be approached to talk about remedies for non-compliance with hand washing, cleaning contracts, queues, nursingstandards etc.

We are looking for co-sponsors for what we would like to be a freeevent. PPIFO ( http://www.ppifo.org.uk) is not grant aided.
http://www.ppifo.org.uk/http://www.ppifo.org.uk/


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The Pendulum" by Baker and Blackburn. Huygens 1665 saw clockpendulums sy nchron ize hanging on the same wal l .

A class ical example of the weak dr iving, stro ng co upl ing case.

Weak d r iv ing w i th s t rong coupl ing

produces synchronisation or coherence-

and narrow stat ist ical var iance onoutcomes.

St rong dr iv ing w i th weak coup l ing

produces unsynchronisat ion or

decoherence- and w ide var iance on

outcomes.

Safe Diagnosis 2

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