scholarly journals Should electronic differential diagnosis support be used early or late in the diagnostic process? A multicentre experimental study of Isabel

2021 ◽  
pp. bmjqs-2021-013493
Author(s):  
Matt Sibbald ◽  
Sandra Monteiro ◽  
Jonathan Sherbino ◽  
Andrew LoGiudice ◽  
Charles Friedman ◽  
...  
Keyword(s):  
Internal Medicine ◽  
Emergency Medicine ◽  
Differential Diagnosis ◽  
Correct Diagnosis ◽  
Diagnostic Errors ◽  
Chief Complaint ◽  
Diagnostic Process ◽  
Early Use ◽  
Complete History ◽  
Diagnostic Support

BackgroundDiagnostic errors unfortunately remain common. Electronic differential diagnostic support (EDS) systems may help, but it is unclear when and how they ought to be integrated into the diagnostic process.ObjectiveTo explore how much EDS improves diagnostic accuracy, and whether EDS should be used early or late in the diagnostic process.Setting6 Canadian medical schools. A volunteer sample of 67 medical students, 62 residents in internal medicine or emergency medicine, and 61 practising internists or emergency medicine physicians were recruited in May through June 2020.InterventionParticipants were randomised to make use of EDS either early (after the chief complaint) or late (after the complete history and physical is available) in the diagnostic process while solving each of 16 written cases. For each case, we measured the number of diagnoses proposed in the differential diagnosis and how often the correct diagnosis was present within the differential.ResultsEDS increased the number of diagnostic hypotheses by 2.32 (95% CI 2.10 to 2.49) when used early in the process and 0.89 (95% CI 0.69 to 1.10) when used late in the process (both p<0.001). Both early and late use of EDS increased the likelihood of the correct diagnosis being present in the differential (7% and 8%, respectively, both p<0.001). Whereas early use increased the number of diagnostic hypotheses (most notably for students and residents), late use increased the likelihood of the correct diagnosis being present in the differential regardless of one’s experience level.Conclusions and relevanceEDS increased the number of diagnostic hypotheses and the likelihood of the correct diagnosis appearing in the differential, and these effects persisted irrespective of whether EDS was used early or late in the diagnostic process.

scholarly journals Errors in Differential Diagnosis of Burn Injury at the Prehospital Stage

2021 ◽  
Vol 9 (4) ◽  
pp. 659-665
Author(s):  
O. S. Pankrateva ◽  
Yu. V. Yurova ◽  
P. K. Krylov ◽  
E. V. Zinoviev ◽  
D. O. Vagner ◽  
...  
Keyword(s):  
Differential Diagnosis ◽  
Emergency Care ◽  
Burn Injury ◽  
Correct Diagnosis ◽  
Diagnostic Errors ◽  
Differential Diagnostics ◽  
Diagnostic Process ◽  
Medical Department ◽  
Emergency Medical ◽  
Inpatient Department

Relevance. An important component of the diagnostic process in combustiology is the collection of anamnesis. At the same time, verification of the very fact of a burn injury of the skin, as a rule, does not seem to be a difficult task even for a novice doctor. However, specialists from the I.I. Dzhanelidze Institute regularly encounter errors in the differential diagnosis of burn injuries at the prehospital stage on the part of both ambulance teams (EMS) and surgeons (traumatologists) of non-specialized medical institutions. Each such case attracts attention and takes up a significant part of the time resource of the entire staff of the inpatient department of the emergency medical service for the process of clarifying and verifying the correct diagnosis, as well as determining the further routing of such a patient.Aim of study. To study the structure of diagnostic errors at the prehospital stage of the EMS to optimize patient routing by improving the existing organizational and methodological standards.Material and methods. A retrospective analysis of the case histories of all victims who were admitted to the inpatient department of the Emergency Medical Department of the I.I. Dzhanelidze St. Petersburg Research Institute of Emergency Medicine during the period from January 2018 to December 2019.Results. 4,951 patients were admitted with a leading diagnosis of the referring institution, suggesting a history of burn injury. The incidence of diagnostic errors at the prehospital stage of emergency care was 410 cases (8.3%), while burn injury was completely excluded in 178 cases (3.6%).Conclusions. 1. The results of the analysis revealed a high incidence of diagnostic errors at the prehospital stage of emergency care (8.3%), the main reason for which is the lack of awareness of differential diagnostics within the narrow specialty (combustiology) of primary contact physicians. 2. Shown is the introduction of training practice for doctors and paramedics of emergency medical services, surgeons and traumatologists of primary care in combustiology cycles in specialized burn departments. 3.In order to ensure continuity in the process of providing medical care to patients with burns, it is necessary to create a unified database of convalescents to form a feedback channel with the outpatient clinic during the implementation of the rehabilitation complex.

Can conversation analytic findings help with differential diagnosis in routine seizure clinic interactions?

2016 ◽  
Vol 12 (1) ◽  
pp. 13-24 ◽  
Author(s):  
Katie Ekberg ◽  
Markus Reuber
Keyword(s):  
Differential Diagnosis ◽  
Correct Diagnosis ◽  
Diagnostic Errors ◽  
Epileptic Seizures ◽  
Routine Clinical Setting ◽  
Choice Of Treatment ◽  
Transient Loss ◽  
Factual Content ◽  
Patient’S History ◽  
Linguistic Methods

There are many areas in medicine in which the diagnosis poses significant difficulties and depends essentially on the clinician’s ability to take and interpret the patient’s history. The differential diagnosis of transient loss of consciousness (TLOC) is one such example, in particular the distinction between epilepsy and ‘psychogenic’ non-epileptic seizures (NES) is often difficult. A correct diagnosis is crucial because it determines the choice of treatment. Diagnosis is typically reliant on patients’ (and witnesses’) descriptions; however, conventional methods of history-taking focusing on the factual content of these descriptions are associated with relatively high rates of diagnostic errors. The use of linguistic methods (particularly conversation analysis) in research settings has demonstrated that these approaches can provide hints likely to be useful in the differentiation of epileptic and non-epileptic seizures. This paper explores to what extent (and under which conditions) the findings of these previous studies could be transposed from a research into a routine clinical setting.

Incidence of diagnostic errors in unplanned hospitalized patients using an automated medical history-taking system with differential diagnosis generator: retrospective observational study (Preprint)

2021 ◽  
Author(s):  
Ren Kawamura ◽  
Yukinori Harada ◽  
Shu Sugimoto ◽  
Yuichiro Nagase ◽  
Shinichi Katsukura ◽  
...  
Keyword(s):  
Internal Medicine ◽  
Differential Diagnosis ◽  
Clinical Practice ◽  
Medical History ◽  
Diagnostic Errors ◽  
Clinical History ◽  
Final Diagnosis ◽  
Outpatient Department ◽  
Medical History Taking ◽  
History Taking

BACKGROUND Automated medical history-taking systems that generate differential diagnosis lists have been suggested to contribute to improved diagnostic accuracy. However, the effect of this system on diagnostic errors in clinical practice remains unknown. OBJECTIVE This study aimed to assess the incidence of diagnostic errors in an outpatient department, where an artificial intelligence (AI)-driven automated medical history-taking system that generates differential diagnosis lists was implemented in clinical practice. METHODS We conducted a retrospective observational study using data from a community hospital in Japan. We included patients aged 20 and older who used an AI-driven automated medical history-taking system that generates differential diagnosis lists in the outpatient department of internal medicine for whom the index visit was between July 1, 2019, and June 30, 2020, followed by unplanned hospitalization within 14 days. The primary endpoint was the incidence of diagnostic errors, which were detected using the Revised Safer Dx instrument by at least two independent reviewers. To evaluate the differential diagnosis list of AI on the incidence of diagnostic errors, we compared the incidence of diagnostic errors between the groups in which AI generated the final diagnosis in the differential diagnosis list and in which AI did not generate the final diagnosis in the differential diagnosis list; Fisher’s exact test was used for comparison between these groups. For cases with confirmed diagnostic errors, further review was conducted to identify the contributing factors of diagnostic errors via discussion among the three reviewers, using the Safer Dx Process Breakdown Supplement as a reference. RESULTS A total of 146 patients were analyzed. The final diagnosis was confirmed in 138 patients and the final diagnosis was observed in the differential diagnosis list of the AI in 69 patients. Diagnostic errors occurred in 16 of 146 patients (11.0%; 95% confidence interval, 6.4-17.2%). Although statistically insignificant, the incidence of diagnostic errors was lower in cases in which the final diagnosis was included in the differential diagnosis list of AI than in cases in which the final diagnosis was not included (7.2% vs. 15.9%, P=.18). Regarding the quality of clinical history taken by AI, the final diagnosis was easily assumed by reading only the clinical history taken by the system in 11 of 16 cases (68.8%). CONCLUSIONS The incidence of diagnostic errors in the internal medicine outpatients used an automated medical history-taking system that generates differential diagnosis lists seemed to be lower than the previously reported incidence of diagnostic errors. This result suggests that the implementation of an automated medical history-taking system that generates differential diagnosis lists could be beneficial for diagnostic safety in the outpatient department of internal medicine.

A 10-year-old child with acute torticollis due to polymicrobial deep neck infection

2022 ◽  
Vol 15 (1) ◽  
pp. e244331
Author(s):  
Alex Guri ◽  
Eric Scheier
Keyword(s):  
Emergency Department ◽  
Differential Diagnosis ◽  
Point Of Care ◽  
Correct Diagnosis ◽  
Point Of Care Ultrasound ◽  
Deep Neck Infection ◽  
Eikenella Corrodens ◽  
Neck Infection ◽  
Streptococcus Constellatus ◽  
Early Use

Torticollis in children can be a sign of a potentially dangerous disease; the correct diagnosis is not always obvious on history and physical examination. The use of point-of-care ultrasound (POCUS) helps to limit the differential diagnosis and direct appropriate further laboratory and radiology-performed evaluation. We present a case of a 10-year-old child whose deep neck infection (DNI) was timely diagnosed in the paediatric emergency department by early use of POCUS and drained under POCUS guidance after admission to the hospital. The culture from the fluid grew Eikenella corrodens, Streptococcus constellatus and Prevotella buccae. This case demonstrates that DNIs occur in children with acute acquired torticollis, even without fever and demonstrates the importance of early use of POCUS in cases where DNI is a potential diagnosis. Moreover, this case emphasises the importance of microbiological identification of DNIs that can be the key to successful treatment.

scholarly journals The relationship between time to diagnose and diagnostic accuracy among internal medicine residents: a randomized experiment

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
J. Staal ◽  
J. Alsma ◽  
S. Mamede ◽  
A. P. J. Olson ◽  
G. Prins-van Gilst ◽  
...  
Keyword(s):  
Internal Medicine ◽  
Diagnostic Accuracy ◽  
Cognitive Biases ◽  
Correct Diagnosis ◽  
Diagnostic Errors ◽  
Slowing Down ◽  
Availability Bias ◽  
Internal Medicine Residents ◽  
Within Subjects ◽  
The Relationship

Abstract Background Diagnostic errors have been attributed to cognitive biases (reasoning shortcuts), which are thought to result from fast reasoning. Suggested solutions include slowing down the reasoning process. However, slower reasoning is not necessarily more accurate than faster reasoning. In this study, we studied the relationship between time to diagnose and diagnostic accuracy. Methods We conducted a multi-center within-subjects experiment where we prospectively induced availability bias (using Mamede et al.’s methodology) in 117 internal medicine residents. Subsequently, residents diagnosed cases that resembled those bias cases but had another correct diagnosis. We determined whether residents were correct, incorrect due to bias (i.e. they provided the diagnosis induced by availability bias) or due to other causes (i.e. they provided another incorrect diagnosis) and compared time to diagnose. Results We did not successfully induce bias: no significant effect of availability bias was found. Therefore, we compared correct diagnoses to all incorrect diagnoses. Residents reached correct diagnoses faster than incorrect diagnoses (115 s vs. 129 s, p < .001). Exploratory analyses of cases where bias was induced showed a trend of time to diagnose for bias diagnoses to be more similar to correct diagnoses (115 s vs 115 s, p = .971) than to other errors (115 s vs 136 s, p = .082). Conclusions We showed that correct diagnoses were made faster than incorrect diagnoses, even within subjects. Errors due to availability bias may be different: exploratory analyses suggest a trend that biased cases were diagnosed faster than incorrect diagnoses. The hypothesis that fast reasoning leads to diagnostic errors should be revisited, but more research into the characteristics of cognitive biases is important because they may be different from other causes of diagnostic errors.

Using computerized virtual cases to explore diagnostic error in practicing physicians

Diagnosis ◽  
2018 ◽  
Vol 5 (4) ◽  
pp. 229-233
Author(s):  
Robert L. Trowbridge ◽  
James B. Reilly ◽  
Jerome C. Clauser ◽  
Steven J. Durning
Keyword(s):  
Correct Diagnosis ◽  
Diagnostic Errors ◽  
Diagnostic Error ◽  
Outcome Data ◽  
Diagnostic Process ◽  
Patient Harm ◽  
Physician Performance ◽  
Two Phases ◽  
Adaptive Nature ◽  
Practicing Physicians

Abstract Background Diagnostic errors are a significant cause of patient harm. Cognitive processes often contribute to diagnostic errors but studying and mitigating the effects of these errors is challenging. Computerized virtual patients may provide insight into the diagnostic process without the potential for patient harm, but the feasibility and utility of using such cases in practicing physicians has not been well described. Methods We developed a series of computerized virtual cases depicting common presentations of disease that included contextual factors that could result in diagnostic error. Cases were piloted by practicing physicians in two phases and participant impressions of the case platform and cases were recorded, as was outcome data on physician performance. Results Participants noted significant challenges in using the case platform. Participants specifically struggled with becoming familiar with the platform and adjusting to the non-adaptive and constraining processes of the model. Although participants found the cases to be typical presentations of problems commonly encountered in practice, the correct diagnosis was identified in less than 33% of cases. Conclusions The development of virtual patient cases for use by practicing physicians requires substantial resources and platforms that account for the non-linear and adaptive nature of reasoning in experienced clinicians. Platforms that are without such characteristics may negatively affect diagnostic performance. The novelty of such platforms may also have the potential to increase cognitive load. Nonetheless, virtual cases may have the potential to be a safe and robust means of studying clinical reasoning performance.

scholarly journals Prevalence and characterisation of diagnostic error among 7-day all-cause hospital medicine readmissions: a retrospective cohort study

2020 ◽  
Vol 29 (12) ◽  
pp. 971-979 ◽  
Author(s):  
Katie E Raffel ◽  
Molly A Kantor ◽  
Peter Barish ◽  
Armond Esmaili ◽  
Hana Lim ◽  
...  
Keyword(s):  
Cohort Study ◽  
Retrospective Cohort Study ◽  
Retrospective Cohort ◽  
Correct Diagnosis ◽  
Diagnostic Errors ◽  
Hospital Medicine ◽  
Diagnostic Error ◽  
Diagnostic Reasoning ◽  
Diagnostic Process ◽  
Patient Morbidity

BackgroundThe prevalence and aetiology of diagnostic error among hospitalised adults is unknown, though likely contributes to patient morbidity and mortality. We aim to identify and characterise the prevalence and types of diagnostic error among patients readmitted within 7 days of hospital discharge.MethodsRetrospective cohort study at a single urban academic hospital examining adult patients discharged from the medical service and readmitted to the same hospital within 7 days between January and December 2018. The primary outcome was diagnostic error presence, identified through two-physician adjudication using validated tools. Secondary outcomes included severity of error impact and characterisation of diagnostic process failures contributing to error.ResultsThere were 391 cases of unplanned 7-day readmission (5.2% of 7507 discharges), of which 376 (96.2%) were reviewed. Twenty-one (5.6%) admissions were found to contain at least one diagnostic error during the index admission. The most common problem areas in the diagnostic process included failure to order needed test(s) (n=11, 52.4%), erroneous clinician interpretation of test(s) (n=10, 47.6%) and failure to consider the correct diagnosis (n=8, 38.1%). Nineteen (90.5%) of the diagnostic errors resulted in moderate clinical impact, primarily due to short-term morbidity or contribution to the readmission.ConclusionThe prevalence of diagnostic error among 7-day medical readmissions was 5.6%. The most common drivers of diagnostic error were related to clinician diagnostic reasoning. Efforts to reduce diagnostic error should include strategies to augment diagnostic reasoning and improve clinician decision-making around diagnostic studies.

scholarly journals Diagnosis is a team sport – partnering with allied health professionals to reduce diagnostic errors

Diagnosis ◽  
2016 ◽  
Vol 3 (2) ◽  
pp. 49-59 ◽  
Author(s):  
Dana B. Thomas ◽  
David E. Newman-Toker
Keyword(s):  
Cultural Change ◽  
Health Professionals ◽  
Medical Diagnosis ◽  
Allied Health ◽  
Physical Therapist ◽  
Correct Diagnosis ◽  
Diagnostic Errors ◽  
Diagnostic Process ◽  
Allied Health Professionals ◽  
Sociocultural Barriers

Abstract: Diagnostic errors are the most common, most costly, and most catastrophic of medical errors. Interdisciplinary teamwork has been shown to reduce harm from therapeutic errors, but sociocultural barriers may impact the engagement of allied health professionals (AHPs) in the diagnostic process.: A qualitative case study of the experience at a single institution around involvement of an AHP in the diagnostic process for acute dizziness and vertigo. We detail five diagnostic error cases in which the input of a physical therapist was central to correct diagnosis. We further describe evolution of the sociocultural milieu at the institution as relates to AHP engagement in diagnosis.: Five patients with acute vestibular symptoms were initially misdiagnosed by physicians and then correctly diagnosed based on input from a vestibular physical therapist. These included missed labyrinthine concussion and post-traumatic benign paroxysmal positional vertigo (BPPV); BPPV called gastroenteritis; BPPV called stroke; stroke called BPPV; and multiple sclerosis called BPPV. As a consequence of surfacing these diagnostic errors, initial resistance to physical therapy input to aid medical diagnosis has gradually declined, creating a more collaborative environment for ‘team diagnosis’ of patients with dizziness and vertigo at the institution.: Barriers to AHP engagement in ‘team diagnosis’ include sociocultural norms that establish medical diagnosis as something reserved only for physicians. Drawing attention to the valuable diagnostic contributions of AHPs may help facilitate cultural change. Future studies should seek to measure diagnostic safety culture and then implement proven strategies to breakdown sociocultural barriers that inhibit effective teamwork and transdisciplinary diagnosis.

Nasce uma nova especialidade : osteopatia

2016 ◽  
Vol 2 (3) ◽  
Author(s):  
Marco Antônio Guimarães Da Silva
Keyword(s):  
Internal Medicine ◽  
Emergency Medicine ◽  
Preventive Medicine ◽  
Rio De Janeiro ◽  
Obstetrics And Gynecology ◽  
Physical Medicine ◽  
National Board ◽  
Physical Medicine And Rehabilitation ◽  
Allergy And Immunology ◽  
Medical Examiners

Por circunstâncias relacionadas à minha titulação, acabei designado pela Universidade Castelo Branco do Rio de Janeiro (UCB) para avaliar uma parceria proposta pela Escola de Osteopatia de Madri (EOM). À época, em 1997, a EOM propunha que a UCB passasse a organizar academicamente os cursos de osteopatia que a referida Escola já vinha ministrando no Brasil, com vistas a, no futuro, torná-lo um curso de pós-graduação. Algumas viagens à Madri para observar a estrutura acadêmica e pedagógica da sede da EOM, condição imposta pela UCB para concretizar a parceria, me levaram a conhecer esta modalidade terapêutica, com resultados efetivamente comprovados através de trabalhos científicos.Realizadas as adaptações que se faziam necessárias, a UCB aprovou, em 2000, o curso de osteopatia, com uma carga horária de 1050 horas para a titulação de especialização acadêmica, nível Lato Sensu. A resolução do COFITO, que estabelece a osteopatia como uma especialidade da fisioterapia, levou-nos a propor ao CEPE da UCB uma complementação de 450 horas, alcançando, assim, as 1.500 horas, distribuídas ao longo de cinco anos, exigidas pela referida resolução do COFITO. A introdução desta técnica terapêutica no Brasil pela corrente Européia e a pronta intervenção do COFITO foram fatores decisivos para nos brindar com mais uma especialidade. Houvera sido a Osteopatia implantada no Brasil por influência da escola americana, talvez os rumos tomados fossem outros. Senão, vejamos. Nos EUA, a osteopatia é normalmente exercida pelo médico, que deve obter sua permissão através do National Board of Osteopatic Medical Examiners, e está dividida em Sociedades Osteopáticas que se distribuem por todas as modalidades médicas; a saber: Allergy and Immunology, Anesthesiology, Dermatology ,Emergency Medicine, Internal Medicine, Neurologists and Psychiatrists, Obstetrics and Gynecology, Occupational and Preventive Medicine, Ophthalmology and Otolaryngology, Orthopedics Pathology, Pediatrics Proctology, Radiology, Physical Medicine and Rehabilitation, Rheumatology Sports Surgery Medicine.Com o objetivo de incentivar as linhas de pesquisas na área da osteopatia, estará sendo criado, durante as III Jornadas Hispano-Lusas de Fisioterapia em Terapia Manual (Sevilha-Espanha, 5 de outubro de 2001), o Centro Internacional de Pesquisas em Osteopatia. O referido Centro, dirigido por um fisioterapeuta brasileiro com Doutorado, terá sua sede na Espanha e manterá núcleos, vinculados a Universidades, na Argentina, no Brasil, na Itália, em Portugal e na Venezuela. Esperamos, desta forma, ao lado do reconhecimento profissional já oferecido pela resolução COFITO, dar mais um passo na consolidação acadêmica da nossa mais nova modalidade terapêutica.

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