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diagnostic error (missed diagnosis)

Etiology: - most commonly missed diagnoses: - pneumonia (7%) - congestive heart failure (6%) - acute renal failure (5%) - cancer (5%) - urinary tract infection (5%) - poor history-taking, physical exam, or failure to review the medical record account for ~80% of diagnostic errors - patients with missed diagnoses tend to be older - medical records associated with diagnostic errors tend to show no documentation of a differential diagnosis at the primary encounter Management: - understand diagnostic heuristics [2] a) availability heuristic - diagnosis based upon what is most easily available in the physician's mind (i.e. recent or memorable case ..) b) anchoring (premature closure) - settling on a diagnosis early in the diagnostic process despite data that refute the diagnosis or support another c) representativeness - application of pattern recognition (patient's presentation fits a typical case) thus it must be that case - utilize diagnostic time outs - taking time to periodically review a case without assuming the current diagnosis - plan for worse-case scenario - consider life-threatening diagnoses 1st - use systematic approach to common problems - ask the patient why he/she is sick - what precipitated the current illness - utilize clinical examination - use pretest odds & post-test odds - acknowledge the effect of the patient - physicians may discount important data in patients with whom they have had difficult encounter - physicians close to their patients tend to overestimate prognosis - look for clinical findings that do not fit the diagnosis - consider uncommon diagnoses - slow down & reflect - difficult to do with many physician's workloads - admit mistakes [2] - recognition of limitations may lead to improved quality of care - working in pairs may reduce diagnostic errors among medical students [3] - Institute of Medicine Recommendations [4] - facilitate better teamwork among healthcare workers, patients, & families - find ways to identify & learn from diagnostic errors (systems approach) - health IT that supports patients & healthcare workers through the diagnostic process Notes: - majority of diagnostic errors involve several contributing factors - interventions, including policy changes, should be multifaceted [7]

Related

bias diagnosis

General

medical error

References

  1. Singh H et al Types and Origins of Diagnostic Errors in Primary Care Settings. JAMA Intern Med. 2013;():1-8 PMID: 23440149 http://archinte.jamanetwork.com/article.aspx?articleid=1656540 - Newman-Toker DE and Makary MA Measuring Diagnostic Errors in Primary Care. Comment on "Types and Origins of Diagnostic Errors in Primary Care Settings" JAMA Intern Med. 2013;():1-2 PMID: 23440273 http://archinte.jamanetwork.com/article.aspx?articleid=1656536
  2. Medical Knowledge Self Assessment Program (MKSAP) 16, 17. American College of Physicians, Philadelphia 2012, 2015
  3. Hautz WE et al Diagnostic Performance by Medical Students Working Individually or in Teams. JAMA. 2015;313(3):303-304 PMID: 25603003 http://jama.jamanetwork.com/article.aspx?articleid=2091295
  4. Institute of Medicine Report. September 22, 2015 Improving Diagnosis in Health Care http://iom.nationalacademies.org/Reports/2015/Improving-Diagnosis-in-Healthcare.aspx
  5. Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med. 2003 Aug;78(8):775-80. Review. PMID: 12915363
  6. Saber Tehrani AS, Lee H, Mathews SC et al 25-Year summary of US malpractice claims for diagnostic errors 1986-2010: an analysis from the National Practitioner Data Bank. BMJ Qual Saf. 2013 Aug;22(8):672-80. PMID: 23610443
  7. Cheraghi-Sohi S, Holland F, Singh H et al Incidence, origins and avoidable harm of missed opportunities in diagnosis: longitudinal patient record review in 21 English general practices. BMJ Qual Saf. 2021;Epub Jun 14. https://psnet.ahrq.gov/issue/incidence-origins-and-avoidable-harm-missed-opportunities-diagnosis-longitudinal-patient