The COVID trap: pediatric diagnostic errors in a pandemic world

Abstract Objectives The COVID-19 pandemic has introduced strains in the diagnostic process through uncertainty in diagnosis, changes to usual clinical processes, and introduction of a unique social context of altered health care delivery and fear of the medical environment. These challenges created a context ripe for diagnostic error involving both systems and cognitive factors. Case presentation We present a series of three pediatric cases presenting to care during the early phases of the COVID-19 pandemic that highlight the heightened potential for diagnostic errors in the pandemic context with particular focus on the interplay of systems and cognitive factors leading to delayed and missed diagnoses. These cases illustrate the particular power of availability bias, diagnostic momentum, and premature closure in the diagnostic process. Conclusions Through integrated commentary and a fishbone analysis of the cognitive and systems factors at play, these three cases emphasize the specific influence of the COVID-19 pandemic on pediatric patients.

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Use of patient complaints to identify diagnosis-related safety concerns: a mixed-method evaluation

BMJ Quality & Safety ◽

10.1136/bmjqs-2020-011593 ◽

2021 ◽

pp. bmjqs-2020-011593

Author(s):

Traber D Giardina ◽

Saritha Korukonda ◽

Umber Shahid ◽

Viralkumar Vaghani ◽

Divvy K Upadhyay ◽

...

Keyword(s):

Medical Record ◽

Clinical Care ◽

Diagnostic Testing ◽

Diagnostic Errors ◽

Diagnostic Error ◽

Diagnostic Process ◽

Healthcare Organisation ◽

Safety Concerns ◽

Patient Complaints ◽

Malpractice Claims

BackgroundPatient complaints are associated with adverse events and malpractice claims but underused in patient safety improvement.ObjectiveTo systematically evaluate the use of patient complaint data to identify safety concerns related to diagnosis as an initial step to using this information to facilitate learning and improvement.MethodsWe reviewed patient complaints submitted to Geisinger, a large healthcare organisation in the USA, from August to December 2017 (cohort 1) and January to June 2018 (cohort 2). We selected complaints more likely to be associated with diagnostic concerns in Geisinger’s existing complaint taxonomy. Investigators reviewed all complaint summaries and identified cases as ‘concerning’ for diagnostic error using the National Academy of Medicine’s definition of diagnostic error. For all ‘concerning’ cases, a clinician-reviewer evaluated the associated investigation report and the patient’s medical record to identify any missed opportunities in making a correct or timely diagnosis. In cohort 2, we selected a 10% sample of ‘concerning’ cases to test this smaller pragmatic sample as a proof of concept for future organisational monitoring.ResultsIn cohort 1, we reviewed 1865 complaint summaries and identified 177 (9.5%) concerning reports. Review and analysis identified 39 diagnostic errors. Most were categorised as ‘Clinical Care issues’ (27, 69.2%), defined as concerns/questions related to the care that is provided by clinicians in any setting. In cohort 2, we reviewed 2423 patient complaint summaries and identified 310 (12.8%) concerning reports. The 10% sample (n=31 cases) contained five diagnostic errors. Qualitative analysis of cohort 1 cases identified concerns about return visits for persistent and/or worsening symptoms, interpersonal issues and diagnostic testing.ConclusionsAnalysis of patient complaint data and corresponding medical record review identifies patterns of failures in the diagnostic process reported by patients and families. Health systems could systematically analyse available data on patient complaints to monitor diagnostic safety concerns and identify opportunities for learning and improvement.

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Lessons in clinical reasoning – pitfalls, myths, and pearls: the contribution of faulty data gathering and synthesis to diagnostic error

Diagnosis ◽

10.1515/dx-2019-0108 ◽

2021 ◽

Vol 0 (0) ◽

Author(s):

Martin A. Schaller-Paule ◽

Helmuth Steinmetz ◽

Friederike S. Vollmer ◽

Melissa Plesac ◽

Felix Wicke ◽

...

Keyword(s):

Patient Safety ◽

Clinical Reasoning ◽

Data Gathering ◽

Diagnostic Errors ◽

Diagnostic Error ◽

Care Physician ◽

Diagnostic Process ◽

Myasthenic Crisis ◽

Hospital Organization ◽

Substantial Impact

Abstract Objectives Errors in clinical reasoning are a major factor for delayed or flawed diagnoses and put patient safety at risk. The diagnostic process is highly dependent on dynamic team factors, local hospital organization structure and culture, and cognitive factors. In everyday decision-making, physicians engage that challenge partly by relying on heuristics – subconscious mental short-cuts that are based on intuition and experience. Without structural corrective mechanisms, clinical judgement under time pressure creates space for harms resulting from systems and cognitive errors. Based on a case-example, we outline different pitfalls and provide strategies aimed at reducing diagnostic errors in health care. Case presentation A 67-year-old male patient was referred to the neurology department by his primary-care physician with the diagnosis of exacerbation of known myasthenia gravis. He reported shortness of breath and generalized weakness, but no other symptoms. Diagnosis of respiratory distress due to a myasthenic crisis was made and immunosuppressive therapy and pyridostigmine were given and plasmapheresis was performed without clinical improvement. Two weeks into the hospital stay, the patient’s dyspnea worsened. A CT scan revealed extensive segmental and subsegmental pulmonary emboli. Conclusions Faulty data gathering and flawed data synthesis are major drivers of diagnostic errors. While there is limited evidence for individual debiasing strategies, improving team factors and structural conditions can have substantial impact on the extent of diagnostic errors. Healthcare organizations should provide the structural supports to address errors and promote a constructive culture of patient safety.

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Lessons in clinical reasoning ‒ pitfalls, myths and pearls: a case of recurrent pancreatitis

Diagnosis ◽

10.1515/dx-2021-0035 ◽

2021 ◽

Vol 0 (0) ◽

Author(s):

Vita Jaspan ◽

Verity Schaye ◽

Andrew S. Parsons ◽

David Kudlowitz

Keyword(s):

Acute Pancreatitis ◽

Clinical Reasoning ◽

Cognitive Biases ◽

Diagnostic Errors ◽

Diagnostic Error ◽

First Episode ◽

Gut Flora ◽

Case Presentation ◽

Early Hypothesis ◽

Elevated Transaminases

Abstract Objectives Cognitive biases can result in clinical reasoning failures that can lead to diagnostic errors. Autobrewery syndrome is a rare, but likely underdiagnosed, condition in which gut flora ferment glucose, producing ethanol. It most frequently presents with unexplained episodes of inebriation, though more case studies are necessary to better characterize the syndrome. Case presentation This is a case of a 41-year old male with a past medical history notable only for frequent sinus infections, who presented with recurrent episodes of acute pancreatitis. In the week prior to his first episode of pancreatitis, he consumed four beers, an increase from his baseline of 1–2 drinks per month. At home, he had several episodes of confusion, which he attributed to fatigue. He underwent laparoscopic cholecystectomy and testing for genetic and autoimmune causes of pancreatitis, which were non-revealing. He was hospitalized 10 more times during that 9-month period for acute pancreatitis with elevated transaminases. During these admissions, he had elevated triglycerides requiring an insulin drip and elevated alcohol level despite abstaining from alcohol for the prior eight months. His alcohol level increased after consumption of complex carbohydrates, confirming the diagnosis of autobrewery syndrome. Conclusions Through integrated commentary on the diagnostic reasoning process, this case underscores how overconfidence can lead to premature closure and anchoring resulting in diagnostic error. Using a metacognitive overview, case discussants describe the importance of structured reflection and a standardized approach to early hypothesis generation to navigate these cognitive biases.

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Checklists to prevent diagnostic errors: a pilot randomized controlled trial

Diagnosis ◽

10.1515/dx-2015-0008 ◽

2015 ◽

Vol 2 (3) ◽

pp. 163-169 ◽

Cited By ~ 8

Author(s):

John W. Ely ◽

Mark A. Graber

Keyword(s):

Primary Care ◽

Usual Care ◽

Error Rate ◽

Primary Care Physicians ◽

Diagnostic Errors ◽

Diagnostic Error ◽

Diagnostic Process ◽

Emergency Physicians ◽

Mean Error ◽

Premature Closure

AbstractMany diagnostic errors are caused by premature closure of the diagnostic process. To help prevent premature closure, we developed checklists that prompt physicians to consider all reasonable diagnoses for symptoms that commonly present in primary care.We enrolled 14 primary care physicians and 100 patients in a randomized clinical trial. The study took place in an emergency department (5 physicians) and a same-day access clinic (9 physicians). The physicians were randomized to usual care vs. diagnostic checklist. After completing the history and physical exam, checklist physicians read aloud a differential diagnosis checklist for the chief complaint. The primary outcome was diagnostic error, which was defined as a discrepancy between the diagnosis documented at the acute visit and the diagnosis based on a 1-month follow-up phone call and record review.There were 17 diagnostic errors. The mean error rate among the seven checklist physicians was not significantly different from the rate among the seven usual-care physicians (11.2% vs. 17.8%; p=0.46). In a post-hoc subgroup analysis, emergency physicians in the checklist group had a lower mean error rate than emergency physicians in the usual-care group (19.1% vs. 45.0%; p=0.04). Checklist physicians considered more diagnoses than usual-care physicians during the patient encounters (6.5 diagnoses [SD 4.2] vs. 3.4 diagnoses [SD 2.0], p<0.001).Checklists did not improve the diagnostic error rate in this study. However further development and testing of checklists in larger studies may be warranted.

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The psychology of diagnostic error

Experimental Psychology (Russia) ◽

10.17759/exppsy.2015080309 ◽

2015 ◽

Vol 8 (3) ◽

pp. 91-98

Author(s):

L. Zwaan

Keyword(s):

Diagnostic Errors ◽

Diagnostic Error ◽

Dual Process ◽

Dual Process Theory ◽

Process Theory ◽

Diagnostic Process ◽

Cognitive Errors ◽

System 2 ◽

System 1 ◽

Analytic Reasoning

Diagnostic errors in medicine occur frequently and the consequences for the patient can be severe. Cognitive errors as well as system related errors contribute to the occurrence of diagnostic error, but it is generally accepted that cognitive errors are the main contributor. The diagnostic reasoning process in medicine, is an understudied area of research. One reason is because of the complexity of the diagnostic process and therefore the difficulty to measure diagnostic errors and the causes of diagnostic error. In this paper, I discuss some of the complexities of the diagnostic process. I describe the dual-process theory, which defines two reasoning modes, 1. a fast, automatic and unconscious reasoning mode called system 1, and a slow and analytic reasoning mode called system 2. Furthermore, the main cognitive causes of diagnostic error are described.

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Mind the overlap: how system problems contribute to cognitive failure and diagnostic errors

Diagnosis ◽

10.1515/dx-2018-0014 ◽

2018 ◽

Vol 5 (3) ◽

pp. 151-156 ◽

Cited By ~ 8

Author(s):

Ashwin Gupta ◽

Molly Harrod ◽

Martha Quinn ◽

Milisa Manojlovich ◽

Karen E. Fowler ◽

...

Keyword(s):

Information Processing ◽

Data Gathering ◽

Diagnostic Errors ◽

Organizational Structures ◽

Diagnostic Error ◽

Diagnostic Process ◽

Cognitive Errors ◽

Data Verification ◽

Consulting Services ◽

Cognitive Failure

Abstract Background Traditionally, research has examined systems- and cognitive-based sources of diagnostic error as individual entities. However, half of all errors have origins in both domains. Methods We conducted a focused ethnography of inpatient physicians at two academic institutions to understand how systems-based problems contribute to cognitive errors in diagnosis. Medicine teams were observed on rounds and during post-round work after which interviews were conducted. Field notes related to the diagnostic process and the work system were recorded, and findings were organized into themes. Using deductive content analysis, themes were categorized based on a published taxonomy to link systems-based contributions and cognitive errors such as faulty data gathering, information processing, data verification and errors associated with multiple domains. Results Observations, focus groups and interviews of 10 teams were conducted between January 2016 and April 2017. The following themes were identified: (1) challenges with interdisciplinary communication and communication within the electronic medical record (EMR) contributed to faulty data gathering; (2) organizational structures such as the operation of consulting services in silos promoted faulty information processing; (3) care handoffs led to faulty data verification and (4) interruptions, time constraints and a cluttered physical environment negatively influenced multiple cognitive domains. Conclusions Systems-based factors often facilitate and promote cognitive problems in diagnosis. Linking systems-based contributions to downstream cognitive impacts and intervening on both in tandem may help prevent diagnostic errors.

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Five things to know about diagnostic error

Diagnosis ◽

10.1515/dx-2016-0043 ◽

2017 ◽

Vol 4 (1) ◽

pp. 13-15 ◽

Cited By ~ 2

Author(s):

Darya Yermak ◽

Peter Cram ◽

Janice L. Kwan

Keyword(s):

Patient Safety ◽

Information Technologies ◽

Safety Issue ◽

Diagnostic Errors ◽

Diagnostic Error ◽

Cognitive Errors ◽

Health Information Technologies ◽

Education And Health ◽

Patient Safety Issue ◽

Missed Diagnoses

AbstractDiagnostic error represents an important patient safety issue. Herein, we summarize five important things to know about this topic. (1) At least 1 in 20 adults are affected by diagnostic errors annually. (2) The root causes for diagnostic errors are typically multifactorial. (3) Cognitive errors are found in the majority of cases. (4) Most missed diagnoses involve common conditions. (5) Advancements in policy, education, and health information technologies hold promise for improving diagnostic safety.

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Recommendations for using the Revised Safer Dx Instrument to help measure and improve diagnostic safety

Diagnosis ◽

10.1515/dx-2019-0012 ◽

2019 ◽

Vol 6 (4) ◽

pp. 315-323 ◽

Cited By ~ 8

Author(s):

Hardeep Singh ◽

Arushi Khanna ◽

Christiane Spitzmueller ◽

Ashley N.D. Meyer

Keyword(s):

Health Care ◽

Data Collection ◽

Medical Record ◽

Diagnostic Errors ◽

Diagnostic Error ◽

Diagnostic Process ◽

Sources Of Information ◽

Missed Opportunities ◽

Health Care Settings ◽

Data Collection Instrument

Abstract The medical record continues to be one of the most useful and accessible sources of information to examine the diagnostic process. However, medical record review studies of diagnostic errors have often used subjective judgments and found low inter-rater agreement among reviewers when determining the presence or absence of diagnostic error. In our previous work, we developed a structured data-collection instrument, called the Safer Dx Instrument, consisting of objective criteria to improve the accuracy of assessing diagnostic errors in primary care. This paper proposes recommendations on how clinicians and health care organizations could use the Revised Safer Dx Instrument in identifying and understanding missed opportunities to make correct and timely diagnoses. The instrument revisions addressed both methodological and implementation issues identified during initial use and included refinements to the instrument to allow broader application across all health care settings. In addition to leveraging knowledge from piloting the instrument in several health care settings, we gained insights from multiple researchers who had used the instrument in studies involving emergency care, inpatient care and intensive care unit settings. This allowed us to enhance and extend the scope of this previously validated data collection instrument. In this paper, we describe the refinement process and provide recommendations for application and use of the Revised Safer Dx Instrument across a broad range of health care settings. The instrument can help users identify potential diagnostic errors in a standardized way for further analysis and safety improvement efforts as well as provide data for clinician feedback and reflection. With wider adoption and use by clinicians and health systems, the Revised Safer Dx Instrument could help propel the science of measuring and reducing diagnostic errors forward.

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Using the NAM diagnostic process framework to teach clinical reasoning in computerized case presentations to 251 medical students

Diagnosis ◽

10.1515/dx-2020-0031 ◽

2020 ◽

Vol 0 (0) ◽

Author(s):

Yvonne Covin ◽

Palma Longo ◽

Neda Wick ◽

Katherine Gavinski ◽

Blake Barker ◽

...

Keyword(s):

Medical Students ◽

Instructional Strategy ◽

Diagnostic Errors ◽

Diagnostic Reasoning ◽

Diagnostic Process ◽

Major Barrier ◽

Case Presentation ◽

Summary Statement ◽

Preclinical Medical Students ◽

Case Presentations

AbstractObjectivesExplicit education on diagnostic reasoning is underrepresented relative to the burden of diagnostic errors. Medical educators report curricular time is a major barrier to implementing new curricula. The authors propose using concise student-identified educational opportunities -- differential diagnosis and summary statement writing -- to justify curriculum development in diagnostic reasoning.MethodsEighteen clerkship and 235 preclinical medical students participated in a 1 h computerized case presentation and facilitated discussion. Students were surveyed on their attitudes toward the case.ResultsAll 18 (100% response) clerkship students and 121 of the 235 preclinical students completed the survey. Students felt the module was effective and relevant. They proposed medical schools consider longitudinal computerized case presentations as an educational strategy.ConclusionsA computerized case presentation is a concise instructional strategy to teach critical points in diagnosis to clerkship and preclinical medical students.

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Inaccurate or delayed diagnosis of hollow organ perforation by emergency physicians: using a qualitative approach to identify the causes

Diagnosis ◽

10.1515/dx-2016-0017 ◽

2016 ◽

Vol 3 (3) ◽

pp. 115-121

Author(s):

Chi-Chun Peng ◽

Chaou-Shune Lin ◽

Peter Woo ◽

Henry Chih-Hung Tai ◽

Cho-Chao Feng

Keyword(s):

Delayed Diagnosis ◽

Diagnostic Errors ◽

Diagnostic Error ◽

Qualitative Approach ◽

Diagnostic Process ◽

Valuable Insight ◽

Emergency Physicians ◽

Structured Interviews ◽

Essential Information ◽

Hollow Organ

AbstractBackground:Mistakes or delays in the diagnosis of hollow organ perforation may be detrimental to prognosis. Nonetheless, emergency physicians (EPs) are prone to misdiagnosing this condition in specific scenarios. The factors leading to errors in their cognitive processes, however, have received little attention.Methods:Using a qualitative approach, we conducted in-depth semi-structured interviews with EPs in the emergency departments (EDs) of three hospitals in Taiwan. We purposively selected participants to obtain a sample that can contribute essential information about the diagnostic process. Sampling continued until new information was no longer being gathered. All interviews were audio-recorded, transcribed verbatim, and then analyzed by two investigators according to grounded theory.Results:Based on 23 cases from 20 EPs, four themes emerged from the analysis regarding the reasons for diagnostic errors: (1) atypical disease presentations (6/23; 26%), (2) cognitive process of the physicians (21/23; 91%), (3) systemic factors (14/23; 61%), and (4) composite factors (14/23; 61%).Conclusions:These findings provide valuable insight into the factors that contribute to diagnostic error in cases of abdominal hollow organ perforation. The results offer a basis on which to build a framework for teaching physicians how to avoid misdiagnosing hollow organ perforation in the future.

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