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Report on MLA CE Course “Diagnostic Error: Team Up and Tackle It!”

by Erica Bass, BS, MLS, Library Director
Jerry L. Pettis VA Memorial Medical Center
Loma Linda, CA

On November 15, I attended the six-hour Medical Library Association Continuing Education class Diagnostic Error: Team Up and Tackle It! The course was offered in conjunction with the Diagnostic Error in Medicine: 5th International Conference held in Baltimore, MD, November 12-14, and sponosored by the Johns Hopkins School of Medicine. Instructors for the course were Lorri Zipperer, Elaine Alligood, Linda Williams, and NN/LM MidContinental Region Library Advocacy Coordinator, Barb Jones. The overall goal of the course is to cover how multidisciplinary teams contribute to the reduction of diagnostic error, with a focus on evidence-based processes, and the impact of librarians. The course breaks down the diagnostic process into components, to reveal how medical misdiagnosis occurs.

Everyone has heard of medical errors, but just how prevalent are they? Statistics show that medical errors account for 98,000 deaths each year. To put this figure in perspective; this is the equivalent to a jumbo jet crash every other day! An even more startling statistic is that the 98,000 deaths per year only includes inpatient populations; excluding completely any outpatients. However, the “outpatient” Emergency Room (ER) is where most misdiagnoses occur. It is estimated that 53% of all diagnoses in the emergency room are incorrect, delayed or missed. ER physicians are the first to acknowledge their role as medical traffic cops. With little time to spare, their goal is to make certain that the ABCs which sustain life are in good working order i.e., Airway, Breathing, and Circulation. Accurate diagnosis of an unusual condition may or may not occur.

Odd as it may seem, no hospital currently measures diagnostic errors on their score cards, and wrong/delayed or incorrect diagnoses are not tracked as part of performance measures. We measure so many things in medicine; why are diagnostic errors such low hanging fruit on the root cause analysis tree? Physicians are remarkably skillful at balancing a myriad of tasks, but unfortunately a large number of medical errors occur with little-to-no consequences. On a daily basis physicians deal with quirky system failures, painfully slow lab processing, computer error, and multi-tasking with an assortment of distractions. Unless a diagnostic error results in a sentinel event they are “invisible” in chart reviews. Medical charts show problem lists, but never do they show any type of “thought process” or DDX (differential diagnosis). This is done outside the formal medical chart.

In Diagnostic Error: Team Up and Tackle It! real-life case studies are presented and studied in detail, to determine what went wrong. Sometimes the time involved to make a correct diagnosis was a critical factor, sometimes not. It is amazing how many individual elements play a role in determining the correct diagnosis, and just like a finely tuned orchestra everyone has a key role to play for harmony to occur. The instructors compared statistics of medical errors to statistics in the aviation industry. When a plane crash happens everyone perks up and pays attention. Using the aviation industry as a comparison, your chances of dying in an airplane crash are 1 in 10 million. Compare this to your 1 in 100 chances of dying due to some sort of medical error. So again, why aren’t hospitals measuring diagnostic errors on their scorecards? And more importantly why aren’t we doing more to prevent them?

One complication is that errors are devilishly difficult to “diagnose.” Wrong, delayed, or missed diagnosis; tests that get lost; lack of follow-up; system errors; and cognitive errors. Where does one begin? Autopsy is the “gold standard” to know what went wrong. Looking back gives us an understanding of events that occurred going forward, but it is certainly a goal to get the diagnosis correct prior to autopsy.

Why do errors happen and how can an Informationalist’s expertise assist in preventing these errors? Studies have shown there is something called “Anchoring Bias,” a cognitive trap of allowing first impressions to exert undue influence over the diagnostic process. There are over 13,000 diseases listed in Pubmed, but physicians routinely deal with roughly 100 of these on a day-to-day basis. Sometimes the old adage “if it looks like a duck, walks like a duck, etc.” doesn’t hold true in medicine. What initially looks like an infected scrape on the playground can really be masking the early stages of sepsis. When the patient isn’t responding to a treatment course it is vital to question, ponder, second guess, and go back to the drawing board. “Premature closure” is another factor in missed or misdirected diagnoses. We all like to solve problems quickly and move on. But how often are we wrong with that first guess? There was a study done by the American Board of Internal Medicine test takers, which counted the test takers’ key strokes. It was found that when test takers switched their initial test answers, answers shifted from wrong-to-wrong 30% of the time, right-to-wrong 22% of the time, and wrong-to-correct 50% of the time.

It is estimated that 39% of cervical cancer patients receive a delayed diagnosis. This 39% figure was derived by taking women diagnosed with cervical cancer back in time. It was found that one to two Pap Tests prior to the diagnosis, a minute amount of cancerous cells could be found in the results. Yet there were not enough cancerous cells for the Pap to be reported as anything but normal. This example of missed diagnosis is the test’s lack of sensitivity and specificity, or the inability to pick up trace cells. There are all sorts of issues at play here, but one thing is certain; several studies show that having an embedded information professional on medical rounds, particularly in the outpatient setting, has clearly been demonstrated to have beneficial results in preventing medical errors. We often talk about “proving our worth,” and I can think of no endeavor more worthy then lending a hand in the prevention of missed, delayed or wrong diagnoses!

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