Defining a Conceptual Model for a Future Health Policy and
Quality Program
INTERVENTIONS TO REDUCE DIAGNOSTIC ERRORS IN AMBULATORY CAREMark
Graber, MD, Stephanie Kissam, MPH, Hardeep Singh, MD, MPH, Asta
Sorensen, MA, Nancy Lenfestey, MHA, Elizabeth Tant, BA, Ken
LaBresh, MD, and Kerm Henriksen, PhD
Collaborators: RTI International, Northport Veterans Affairs
Medical Center, Michael E. DeBakey Veterans Affairs Medical Center
and the Houston VA HSR&D Center of Excellence AHRQ Action I
Master Task Order Mechanism, Contract Number HHSA290200600001 Task
8
Sponsored by AHRQ
PROJECT GOALSPerform a comprehensive literature review of
interventions that could reduce diagnostic errors
Identify and pilot test an intervention targeting diagnostic
errors in an ambulatory care settingBLUNT end
SHARP endPatients Clinical Course
SYSTEMMDCommunication, coordination, training, policies,
procedures
CognitiveFRAMEWORK FOR ADVERSE EVENTSThis is the basic framework
we use to understand adverse events in medicine. If a patient is
injured, one can think of the root causes as reflecting one of two
possible problems (or both): the provider erred, usually a
cognitive mistake or slip, or there were inherent flaws in the
healthcare system that contributed to the error. System-related
problems include communications breakdowns, problems coordinating
care, insufficient training, weak policies, problems in the work
environment, and many other factors. So the solutions to diagnostic
errors could focus on the cognitive skills of the provider, on the
characteristics of the healthcare system, or conceivable on the
patient as a possible collaborator in reducing error.
4ETIOLOGY OF DIAGNOSTIC ERRORS
METHODSHandpicked articles: Non-medical databases (business,
psychology, military, engineering)Recommendations from
expertsAnalysis:All articles reviewed by one of three health
service researchersAny questionable inclusions reviewed by
collaborating physicians
PubMed database search: 2000 2010 INCLUSION CRITERIAArticles
describing tested interventions to reduce error in medical
diagnostic settings Studies demonstrating outcome measures in the
field of diagnostic errorsArticles providing a theoretical basis on
how to reduce diagnostic errors (from any field)
EXCLUSION CRITERIAStudies describing inter-rater or observer
variation Articles describing validations of screening instruments,
tests, case reports, or techniques to enhance diagnosis Articles
describing screening instruments, tests, or technology aides
Studies reporting diagnostic error frequency; etiology; or
assessments of provider satisfaction, preference, or acceptance of
interventions
RESULTSTotal number of articles: 949Articles meeting inclusion
criteria:157Tested interventions:37Cognitive: 32System-related:
5Engaging patients:0Suggested interventions:120Hardeep Singh, MD
MPH Houston HSR&D Center of Excellence, Michael E. DeBakey VA
Medical CenterINTERVENTIONS TO REDUCE DIAGNOSTIC ERRORS IN
AMBULATORY CARESYSTEMS INTERVENTIONS
Result of collaboration between RTI International, Northport
Veterans Affairs Medical Center, Michael E. DeBakey Veterans
Affairs Medical Center and the Houston VA HSR&D Center of
Excellence AHRQ Action I Master Task Order Mechanism, Contract
Number HHSA290200600001 Task 8.RTI International is a trade name of
Research Triangle Institute10SYSTEMS FACTORS Communication and
coordination of care issues
(transitions)Teamwork/SupervisionTechnology/equipment related
issuesOrganizational featuresSafety culturePolicy, processes and
procedure related issuesLeadership, management, or personnel
problemsInadequate resources or available expertiseTraining
issues
11History, exam or ordering diagnostic tests for further
work-upPatient-Provider EncounterOrdered tests either not performed
or performed/interpreted incorrectly Diagnostic TestsProblems with
follow-up of abnormal test results or scheduling of follow-up
visitsFollow-up and TrackingLack of appropriate actions on
requested consultation or communication breakdown from consultant
to referring providerReferralsDelay in seeking care or adherence to
appointmentsPatient RelatedLOOKING FOR INTERVENTIONS IN THESE
PROCESS DIMENSIONSGENERAL RESULTSOnly 1 of 5 controlled study; 2
were only post-test evaluationsAll effectiveMost interventions in
the literature were conceptualLack of standardization in process or
outcome measures PATIENTPROVIDER ENCOUNTERChange the process of
care deliveryForm designated trauma response team in ERConduct
comprehensive reexamination in EREstablish educational programs
(suggested only)Reinforce history-taking skillsProvide teamwork
training in medical setting
Perno JF, et al. (2005)Howard J, et al. (2006)2 tested
interventionsDIAGNOSTIC TESTSImplementation of Picture Archiving
and Communication System (PACS) for radiology imagesWeatherburn, G
et al. (2000)One tested intervention FOLLOW-UP AND
TRACKINGImproving delivery of test results through electronic
means
Other suggested interventions: Establish criteria for
communication of abnormal test resultsStandardize steps involved in
the flow of test result informationImprove management and
presentation of test result dataUse an ER manager to monitor
radiology test results reportingCreate processes to ensure easy
retrieval of test result information Develop highly structured
hand-off processes that are performed systematically
2 tested interventionsSingh, H,et al. (2009)Poon, EG, et al.
(2002)suggested onlyPATIENTSNotify patients of test results Address
patient preferences for receiving test resultsCommunicate normal
test resultsUse computerized test results management toolDesignate
patient navigator
No tested interventionsPATIENTSProvide patient access to test
resultsUse online portal Provide access to entire medical
record
Improve patient-clinician communicationConsider cognitive
limitations when taking patient historyConsider communication
strategies to optimize patient understanding of medical
information
Increase patient engagement in health careInvolve patients to
ensure the follow-up of test results
GENERAL INTERVENTIONS (NO SPECIFIC DIMENSION)Manage
error-producing conditions (suggested only)Provide education on
error-producing conditions like fatigueAddress workrelated
conditions that could produce boredom, time pressure, etc.Establish
systematic tracking of diagnostic error in organization (suggested
only)Downstream feedback
CONCLUSIONS SYSTEM ISSUESLimited literature on systems
interventions that reduced diagnostic error in ambulatory care
Empiric data only for 3/5 dimensions of diagnostic process Many
interventions well conceptualized but poorly operationalized as
testable interventions Much discussion of methods to notify
patients of test results, but little focused on abnormal
resultsHealth IT potential and workflow related issues
CONCLUSIONS SYSTEM ISSUESGaps in tested interventions aimed at
patientsEfficacy of patient and family engagement in preventing or
reducing diagnostic error?Multiple organizations and experts
advocate for patient engagement in patient safety, yet limited
studies successfully do so No studies report actual interventions
engaging patients and families in the process of making medical
diagnoses. OPEN DISCUSSION SYSTEM ISSUESQuestion How and when can
we effectively engage patients and families in diagnostic error
reduction? Mark L Graber MD FACP VA Medical Center, Northport NY
& SUNY Stony BrookINTERVENTIONS TO REDUCE DIAGNOSTIC ERRORS IN
AMBULATORY CARECOGNITIVE INTERVENTIONS
Collaborators: RTI International, Northport Veterans Affairs
Medical Center, Michael E. DeBakey Veterans Affairs Medical Center
and the Houston VA HSR&D Center of Excellence AHRQ Action I
Master Task Order Mechanism, Contract Number HHSA290200600001 Task
8.23COGNITIVE ERRORS
COGNITIVE ERRORS Most cognitive errorsinvolve breakdowns in
synthesizing the available data, due to ..
faulty context assumptionspremature closurethe inherent
shortcomings of heuristic (intuitive) thinkingaffective biases and
environmental factors that detract from optimal conditions:
distractions, fatigue, stress, workload
INTERVENTIONS TO REDUCE COGNITIVE ERRORImprove clinical
reasoningGet helpIncrease medical knowledge and expertiseINCREASE
KNOWLEDGE & EXPERTISEIncrease training time & events to
increase experience (3 tested interventions)
Use simulation to provide compacted experience (1 tested
intervention)
Increase feedback to improve calibration and reduce
overconfidence (3 tested interventions)
IMPROVE CLINICAL REASONINGImprove evidence-based medicine
skills, normative decision-making skillsImprove intuitive
decision-makingTeach heuristics & biasesUse de-biasing
techniques; improve metacognitionReflective practice; checklists;
be comprehensive, consider the opposite
suggested onlyNo tested interventionsGET HELPIncrease
consultation, second opinions, fresh eyes
Use decision support tools; increase access to medical knowledge
(web access, texts, info buttons)
10 tested interventions12 tested interventionsCONCLUSIONS -
COGNITIVE FACTORSA broad array of ideas for interventions (N=157),
but few tested (N=37)
Gaps: Most interventions apply to diagnostic specialties
(radiology, pathology, laboratory), not the ED or PCTests have been
done under artificial conditionsLearning assessed only in the short
termTools developed arent used
SUGGESTED PROJECT: CHECKLIST(S)Checklists are ideal in dealing
with COMPLEXITY
Checklists can combine system-based, patient-based, and
cognitive interventions
Checklists are HOT
A GENERAL CHECKLISTObtain YOUR OWN, COMPLETE medical
historyPerform a FOCUSED and PURPOSEFUL physical
examinationGenerate some initial hypotheses and differentiate these
with appropriate questions, examination, or diagnostic testsPause
to reflect Take a diagnostic time out:Was I comprehensive ?Did I
consider the inherent flaws of heuristic thinking ?Was my judgment
affected by any other bias ?Do I need to make the diagnosis NOW, or
can I wait ?Whats the worst case scenario ? What are the dont miss
entities ?Embark on a plan, but acknowledge uncertainty and ENSURE
A PATHWAY FOR FOLLOW-UP
A SYNDROME-SPECIFIC CHECKLISTCHEST PAIN MI PE Pneumonia
Pericarditis Musculoskeletal Gerd Herpes ZosterPleurisy Aortic
stenosisTumors lung, lymphoma, mediastinum Spinal cord compression
Esophageal spasmPsychiatric
OPEN DISCUSSION COGNITIVE ISSUESQuestion Question 2 What would
it take to convince frontline providers to use a checklist
?Question Question Question 3 - Will they help reduce diagnostic
errors, or are we better off just trusting our initial (intuitive)
diagnoses ?
Question 1 Which would be more effective a GENERAL checklist, or
SYNDROME SPECIFIC checklists ?other questions?Measurement of
diagnostic errors?How to evaluate quality of clinical reasoning?How
do you teach this stuff?
ACKNOWLEDGMENTS:AHRQ, RTI, VA