By John E. Barnett, MD, CCHP
Posted on February 12, 2012 – Fifty-two percent of successful malpractice claims are related to outpatient events, with most involving major injury or death. Furthermore, 40% of all malpractice suits are related to missed, delayed, or incorrect diagnoses. These facts alone are more than enough to stimulate our efforts to identify the causes of error and eliminate them in our correctional patients; however, there are many more reasons for the evolving national focus on this kind of adverse event. Diagnostic errors result in elevated costs, increased morbidity, and higher mortality. Recent legislation coupled with increasing involvement and action by regulatory bodies and advocacy organizations are examples of increasing public awareness of the extent of the problem. As we move into a new year and are faced with the ever more complex science and art of medicine, it is necessary that we reflect on how we make diagnoses and how we can reduce diagnostic errors.
Correctional Medicine and Diagnostic Error
Since the practice of correctional medicine is primarily outpatient in nature and diagnostic errors in ambulatory patients have received little attention in the past, it is appropriate that we take a new look at the nature and extent of medical mistakes in our special patient populations.
Correctional medicine provides even more opportunities for diagnostic error than in the average outpatient practice because of factors such as exaggeration of symptoms, multiple comorbidities, and lack of immediate access to consultations, imaging studies, or special tests. Additionally, we are sometimes burdened with inadequate handoff from the hospital, loss of continuity of care with multiple providers, and sudden release of an inmate patient. While most of our diagnoses are made quickly and are proven correct, we all have heard stories of incorrect diagnoses like these:
Metacognition of Diagnostic Errors
Metacognition is the study of the nature of assumptions and structure of thinking. The word literally means thinking about thinking. It is not a new concept and has been around since the time of Aristotle. Metacognition is a well known method used extensively in Mental Health as a form of treatment and now is utilized in medical education. It is ideal for analysis and correction of diagnostic errors because simple techniques are inadequate for understanding this complex process.
Medical errors can be classified as system errors or cognitive errors. System errors account for about two thirds of all medical errors, and have been vigorously investigated by Quality Improvement programs and required monitoring activities. Examples of system malfunction include lack of proper protocol, misfiled reports, poor hand off, lost consultation requests, and communication failures. The remaining one third of medical errors are due to cognitive mistakes.
In 1999, the publication of To Err is Human: Building a Safer Health System provided a powerful stimulus for improving patient safety in hospitals. Initial efforts were directed at medication errors, hospital acquired infections, and what came to be known as never events. Despite 12 years of national efforts, results have been modest. Cognitive errors have received much less attention. While actions to decrease systemic errors have been less effective than expected, efforts to reduce diagnostic errors in outpatients have been almost nonexistent.
Making a diagnosis is largely a thought process. We gather and analyze information using our training, experience and knowledge. It’s a very complex process; therefore, there are numerous opportunities for oversights, mistakes, and misinterpretation to occur. In fact, making a medical diagnosis is remarkably similar to the process of critical decision making in business, the military or personal life. There are a number of influences on our decisions of which we must be aware and consider. The time has come for each of us to carefully consider these factors, and to think about our thinking.
The Detrimental Effect of Bias
Of the many influences on our thinking as we make critical decisions such as diagnoses, bias is perhaps the most problematical. Dr. Michael Robert of Harvard School of Business has stated that Biases are rooted in human nature. They are hard to avoid.
The word bias means a slope or slant. It refers to a mental leaning or inclination, an unfair preference for or against something based on cognitive factors rather than fact or evidence. Synonyms of bias are prejudice, partiality, and predisposition. There are more than 42 kinds of bias identified currently, but seven of these particularly influence our thinking about medical diagnoses. To minimize the harmful effects these have on our thinking and decision making, we need to recognize each one:
There are three other interfering influences on our thought process that must be considered. One is the use of intuition in decision making. Intuition is actually the identification of patterns that we recognize, remember, and understand. It is quite useful, but only if we have accurate knowledge of that particular pattern.
A second bias not mentioned above comes from the frequently heard declaration that Hindsight is always 20/20. But hindsight is never 20/20! It is severely myopic and always biased by our knowledge of the outcome.
A bias that is becoming more influential in health care and which we must particularly avoid in corrections is the sunk cost influence. This occurs when time and costs already invested in a tentative diagnosis are allowed to inappropriately influence and direct the final decision.
A Plan to Prevent Diagnostic Error
After analyzing the diagnostic thinking process, it is important to formulate an individualized plan to prevent or reduce the incidence of diagnostic error. An effective plan will have 3 elements:
Checklists in Medicine
The use of checklists was implemented for pilots after the crash of the famous Boeing B-17 during a demonstration flight in 1935. The Army’s most experienced test pilot lost control of the aircraft shortly after takeoff when he forgot to unlock the flight controls. Investigators of the fatal accident created the checklist to prevent pilots from skipping a step or action they know very well must be done. These brief lists of essential actions were designed to avoid catastrophic mistakes.
Checklists began to be used in medicine when Dr. Peter Pronovost at Johns Hopkins Hospital created a basic 5 step list in 2003 to address the problem of central venous catheter infections in the Intensive Care Unit. This simple technique was so effective in reducing infections and septicemia that the state of Michigan asked for his assistance in reducing their similar problem affecting several facilities in the state. The Michigan study became known as the Keystone Project, published in 2006. The results were incredible with 90% of infections being eliminated.
The remarkable success with a simple list of actions that we already know must be done prompted surgeon Atul Gawande to help develop similar checklists for surgical procedures. He assisted in the development of a pre-operative and post-operative checklist, and one for a surgical Time Out. These have also been effective in reducing such surgical errors as the wrong patient, wrong procedure, and wrong limb surgeries. Dr. Gawande described these developments in his 2009 book The Checklist Manifesto.
A Diagnosis Checklist
The following list is intentionally short and easy to implement and can be a useful culmination of metacognition about cognitive mistakes:
B Have I considered Bias?
I Do I have all the Information needed? (Lab tests, images, reports)
A Do I have an Accurate history?
S Are some System factors involved?
Use this checklist so you do not forget to do what you know very well must be done. Checklists may seem too elementary to be effective, but over the years they have proven their worth in many activities that require sequential critical steps. It is time we make use of this valuable technique in health care. Expand or change the above sample to meet your own needs, and modify it over time as your experience reveals new opportunities for improvement.
Conclusion
We now know that more than half of medical malpractice suits are generated by sentinel events affecting outpatients and that 40 percent of all malpractice litigation is related to missed, delayed, or incorrect diagnoses. These two facts clearly indicate the need for immediate and effective actions. Due to the monitoring and quality improvement requirements of accrediting organizations such as the National Commission on Correctional Health Care, the practice of correctional medicine is ahead of ambulatory care nationally. Nevertheless, objective studies are few, and the risks are many.
In light of the less than optimal performance of national efforts to improve patient safety in hospitalized patients, new and innovative approaches are indicated, especially in the practice of medicine behind the bars. Use of a new technique such as a diagnosis checklist is an innovation whose time has come.
Dr. Barnett is the Medical Director of the Cuyahoga County Corrections Center, in Cleveland.
