Cognitive Errors: How Great Clinicians Reach Wrong Conclusions

Transcription

1 Cognitive Errors: How Great Clinicians Reach Wrong Conclusions DAVID GORDON, MD A SSOC PROFESSOR DEPT OF SURGERY DIV EMERG M ED JAMIE FOX, MD A SSOC PROFESSOR DEPT OF PEDIATRICS DIV HOSP/EMERG MED March 12 th, 2015

2 Prevention Strategies Cognitive Biases Dual-Process Theory Overview of Dx Errors

3 What is Diagnostic Error? Medicine Trauma Mark Graber, MD Missed, Delayed, or Wrong Diagnosis James Reason, PhD The failure of a planned action to achieve its desired goal Hardeep Singh, MD Missed opportunities to make a timely or correct diagnosis

4 An Analysis of Errors Causing Morbidity and Mortality in a Trauma: A Guide for Quality Improvement 122,577 patients admitted to six trauma centers Significant preventable errors in 4% of patients 5.9% preventable or potentially preventable trauma deaths 1,295 total deaths Davis et al., Journal of Trauma, 1992

5

6 Phases of Care CC 21% Resus 53% OR 14% CC 50% OR 26% Errors Resus 36% Preventable Deaths

7 Failure to appropriately evaluate abdomen Most common Errors in neurologic resuscitation 33% resuscitative and 12% overall preventable death Critical Care unrecognized intra-abdominal sepsis, ventilator/pulmonary management, head injury management, hemodynamic monitoring failures

8 Patterns of Errors Contributing to Trauma Mortality Lessons Learned from 2594 Deaths , 401 trauma patient admissions 5.8 % deaths 2.5% deaths had contributing errors Gruen et al., Annals of Surgery, 2006

9 Major Patterns of Error Contributing to Mortality Hemorrhage Control Abdomen/Pelvic (16%) Intrathoracic (9%) Airway management (16%) Inappropriate management of unstable patient (14%) Lengthy initial operative procedure (8%) Procedure complication (12%) Inadequate prophylaxis (11%) Missed or delayed diagnosis (11%) Overresuscitation with fluids (5%)

10 Overview of Dx Errors

11 How common is diagnostic error? US Up to 80,000 deaths/year Your Hospital 10 deaths/year 1/1000 outpt encounters 1 diagnostic harm/day Error-related Harm 1/20 adult outpt 12million adults/yr Diagnostic Error Adapted from Dr. Mark Graber s MD, FACP webinar on 12/3/13: Preventing Diagnostic Error: Where do I start? Sponsored by National Patient Safety Foundation

12 Graber M et al. Arch Int Med. 2005;1493.

13 Cognitive Errors Faulty Knowledge Faulty Data Gathering Faulty Synthesis: Verification Faulty Synthesis: Info Processing Graber M et al. Arch Int Med. 2005;1493.

14 Dual-Process Theory Overview of Dx Errors

15 Dual-Process Reasoning Deliberate METACOGNITI ON Unconscious System 1 Non-analytical System 2 Analytical Conscious INTUITION Rapid Quirk M. Intuition and Metacognition in Medical Education: Keys to Developing Expertise

16 System 1: Intuition NON-ANALYTIC Relies heavily on EXPERIENCE Thinking without thinking FAST Pattern Recognition LOW cognitive load

17 System 2: Metacognition ANALYTIC Deductive reasoning Thinking about one s own thinking SLOW Logical HIGH cognitive load

18 System 1: Intuition PITFALLS Strongly influenced by ambient conditions Atypical presentations Pattern mistaken for something else

19 System 2: Metacognition PITFALL IMPRACTICAL SLOW

20 DUAL PROCESS THEORY Croskerry P. Acad Med. 2009;84:

21 Cognitive Biases Dual-Process Theory Overview of Dx Errors

22 Cognitive Biases Anchoring Tendency to lock onto initial impressions or pieces of information early in the decisionmaking process. Once an anchor is set, it can be difficult to move away from and new information is interpreted around it Courthouse Daiquiri Uncooperative Modeled on:croskerry P. Achieving quality in clinical decision making: cognitive strategies and detection of bias. Acad Emerg Med Nov;9(11): and Lucey C, Winiger D, Shim R. Towards a More Effective Morbidity and Mortality Conference APDIM Spring Meeting, 2004

23 Cognitive Biases Confirmation Tendency to look for and weight confirming evidence to support a diagnosis rather than evidence that refutes it Attempted to hit nurse Leave me alone Modeled on:croskerry P. Achieving quality in clinical decision making: cognitive strategies and detection of bias. Acad Emerg Med Nov;9(11): and Lucey C, Winiger D, Shim R. Towards a More Effective Morbidity and Mortality Conference APDIM Spring Meeting, 2004

24 Cognitive Biases Premature closure Tendency to shut down the decision-making process prematurely, accepting a diagnosis before it has been fully verified Vomiting and Uncooperative d/t alcohol consumption Modeled on:croskerry P. Achieving quality in clinical decision making: cognitive strategies and detection of bias. Acad Emerg Med Nov;9(11): and Lucey C, Winiger D, Shim R. Towards a More Effective Morbidity and Mortality Conference APDIM Spring Meeting, 2004

25 Cognitive Biases Diagnosis momentum Once diagnostic labels are attached to patients they tend to stick He s drunk Modeled on:croskerry P. Achieving quality in clinical decision making: cognitive strategies and detection of bias. Acad Emerg Med Nov;9(11): and Lucey C, Winiger D, Shim R. Towards a More Effective Morbidity and Mortality Conference APDIM Spring Meeting, 2004

26 Cognitive Biases Availability Heuristic Judge things as being more likely, or frequently occurring, if they more readily come to mind Alcohol as opposed to head bleed as cause of vomiting Modeled on:croskerry P. Achieving quality in clinical decision making: cognitive strategies and detection of bias. Acad Emerg Med Nov;9(11): and Lucey C, Winiger D, Shim R. Towards a More Effective Morbidity and Mortality Conference APDIM Spring Meeting, 2004

27 Cognitive Biases Gambler s fallacy The belief that if a coin is tossed ten times and is heads each time, the 11th toss has a greater chance of being tails We can t have 3 kids w/ appy in 1 shift Modeled on:croskerry P. Achieving quality in clinical decision making: cognitive strategies and detection of bias. Acad Emerg Med Nov;9(11): and Lucey C, Winiger D, Shim R. Towards a More Effective Morbidity and Mortality Conference APDIM Spring Meeting, 2004

28 Cognitive Bias Inherited Thinking Prevalence/ Estimation Alternative/ 2 nd Diagnosis CATEGORIES Patient Context Overattachment Physician Attributes Campbell SG, Croskerry P, and Bond WF. Acad Emerg Med. 2007; 14:

29 Prevention Strategies Cognitive Biases Dual-Process Theory Overview of Dx Errors

30 CHECKLISTS/PROTOCOLS Gruen et al., Annals of Surgery, 2006

31 Cognitive Debiasing Strategies Mental strategies to avoid cognitive error Forced Thinking

32 THE DIAGNOSTIC TIME OUT

33 Forced Thinking What else could it be? Is there anything that doesn t fit? Is it possible that I have more than one problem?

34 Diagnostic Verification Criteria of Validity Adequacy Are all the patient's findings (abnormal or normal) accounted for by the diagnostic hypothesis? Have I explained all the patient s findings? Coherency Is the diagnostic hypothesis pathophysiologically consistent with all the clinical findings? Is there a non-fit?

35 Life Threats Adequacy Consistency/Coherency Else (What else could it be?) Second Problem

36 When should we take a time out? Unexplained Symptom(s) Return visit At-risk patient population Critical condition End of shift

37

38 Milestones RAPID SEQUENCE INTUBATION NOT YET DIAGNOSED TX TIMES FOR INVASIVE INFECTIONS FIBRINOLYTIC FOR ACUTE MI

39 Admission Tags CHEST PAIN NYD Not Yet Diagnosed VOMITING PD SHORTNESS OF BREATH TPD Trying to Prevent Death Parental Distress

40 FEEDBACK LOOP

41 Closing the Loop Night Float Team Patient ED

42 FUTURE DIRECTIONS Challenges Classification Epidemiology

43 Selected References 1. Berenson RA et al. Placing Diagnosis Errors on the Policy Agenda Policy-Agenda.pdf (Accessed July 29, 2014) 2. Berner ES and ML Graber. Overconfidence as a cause of diagnostic error in medicine. Am J Med. 2008;121:S2-S Crandall B and RL Wears. Expanding Perspectives on Misdiagnosis. Am J Med. 2008;121:S Graber ML et al. Diagnostic Error in Internal Medicine. Arch Int Med. 2005;165: Graber ML. Taking steps towards a safer future: measures to promote timely and accurate medical diagnosis. Am J Med. 2008;121:S Schiff GD. Minimizing Diagnostic Error: The Importance of Follow-up and Feedback. Am J Med. 2008;121:S Davis JW et al. An Analysis of Errors Causing Morbidity and Mortality in a Trauma System: A Guide for Quality Improvement. J Trauma 1992;32: Gruen RL et al. Patterns of Errors Contributing to Trauma Mortality. Lessons Learned From 2594 Deaths. Ann Surg. 2006;244: