#diagnostic error

Rumah sakit seharusnya menjadi tempat yang paling aman bagi seseorang yang sedang sakit. Namun, kenyataannya tidak selalu demikian. Di balik gedung-gedung berwarna putih dan denyut kehidupan para tenaga medis yang sibuk bekerja, tersimpan berbagai risiko yang bisa mengancam keselamatan pasien itu sendiri. Bukan karena niat buruk, melainkan karena kompleksitas sistem kesehatan yang begitu renik…

As I have spent more time thinking about clinical software design, my ruminations have become more problem-focused. I have begun to look at specific care delivery problems and how changes in software designs might help or hinder clinical work.   Lately, the problem of diagnostic error as it relates to results management has captured my attention.   […]

  Eric Glazer   Vice President, Physician Engagement and Social Media   Best Doctors, Inc.

In Part 1, we looked at some of the barriers that physicians face related to diagnostic error. Now let’s explore a few solutions to help improve diagnosis.

 The reporting of diagnostic errors has always been inconsistent. Not surprisingly, in a profession that all but demands 100 percent accuracy, the culture can frown on physicians admitting any level of fault.

 When offered choices as to which action would most encourage the reporting of diagnostic errors, a majority (55 percent) of physicians felt confidentiality was an important enticement: Three out of ten (30 percent) physicians felt “incentives for hospitals from state and federal lawmakers to participate in confidential misdiagnosis data gathering and reporting” would be most helpful; 25 percent selected “confidential reporting/data-sharing on misdiagnosis as part of hospital accreditation.” 

Some physicians believe that “increasing the number of national events and conferences devoted to misdiagnosis” (17 percent) would most encourage reporting, while others saw a strong need for “a national voluntary misdiagnosis reporting system” (17 percent). Only 11 percent thought “a local champion that would encourage reporting” was the most beneficial action.

 Although encouraging physicians to report diagnostic errors is an important first step in elevating the issue, preventingerror is even more essential.

 When physicians were asked what they believe would be useful in improving diagnosis, the top three answers selected were “education about commonly misdiagnosed conditions”, “providing clear diagnostic algorithms for critical conditions” and “development of a secure online environment for collaboration with peers on challenging cases.”

These promising solutions to improve diagnosis will form the backdrop for the Diagnostic Error in Medicine 7th International Conference in Atlanta, September 14-17. Organized by the Society to Improve Diagnosis in Medicine (SIDM), the conference will bring together physicians, patients and public policy leaders to focus on topics including:

Reducing Diagnostic Error Through Improvement of Laboratory Test Utilization

Error, Overconfidence and Inadequate Feedback: Prospects for Systems Improvements

Clinical Decision Support — Bedside Tools for Better Diagnosis

Understanding and Misunderstanding Diagnostic Testing: A Source of Diagnostic Error

Placing Diagnosis Errors on the Policy Agenda

   Jennifer Derebery, MD    Associate at House Ear Clinic, Inc    Clinical Professor, Department of Otolaryngology at the University of Southern          California School of Medicine 

Though dizziness symptoms are common, I consider diagnosing the cause challenging due to the complexity of their possible origins. When diagnosing dizziness, I like to use the “three-legged stool” approach that places the brain as the master center of balance or the seat of the stool; with the three legs supporting the seat refer to the dizziness’ origin. The three legs are as labeled:

Vestibular System – The sensory mechanism in the inner ear that detects movement of the head and helps to control balance

Proprioceptive System – The sensory receptors that are found in the skin, muscles and joints that are sensitive to stretch or pressure in the surrounding tissues

Visual System – The sensory receptors in the retina when affected send impulses to the brain that provide visual cues identifying how a person is relative to the other objects they are looking at

Using the “Three-Legged Stool” approach to pinpoint the high level sources of the dizziness, you can begin to refine your original diagnosis. I also, outlined three types of differential diagnosis:

Peripheral – Inner Ear

Central – The Brain

Systemic – Leading to a symptom                             

After going through the basics, make sure to incorporate the patient in the diagnosis.  It is essential to make the patient feel like they are contributing to their own diagnosis, so make it a point to ask the patient two important questions when diagnosing dizziness: 

What the patient means by dizziness

Does the patient feel they are “spinning,” as with vertigo?

Do they feel “drunk” or imbalanced?

Timing of dizziness-  Depending on the time frame, diagnosing the cause of dizziness can vary

Seconds of dizzy sensations could indicate benign positional vertigo

Minutes of dizziness could indicate a circulatory problem

Hours of dizziness could indicate Meniere’s or migraine

Days of dizziness could indicate viral labyrinthitis, and probably excludes the possibility of an inner ear problem

Constant dizziness probably does not indicate a primarily otolaryngological disorder

Whether the patient is experiencing  hearing loss problems in one half of the inner ear can often affect the other

The pattern of the hearing loss can also offer clues to inner ear problems

Presence of hearing loss symptoms, plus the timing of the dizziness, are two strong indicators in the source of dizziness

The severity of the diagnosis can be quickly made through a proper imaging study and physical examination. Determining whether it is a hemorrhage or a central nervous system problem can be accomplished with a simple exam or imaging study.

Recurring symptoms of benign positional vertigo can often indicate migraine. Keys indications are headaches or other forms of head discomfort, but also can include motion-induced dizziness such as spinning or imbalanced sensations, even if they haven’t experienced these symptoms in several years. Ask the patient whether they are bothered by light or loud sound: these symptoms would also indicate possible migraine. For treatment options, watch Diagnosing Dizziness: Tips for the Primary Care Doctor.

 Eric Glazer  Vice President  Physician Engagement and Social Media  Best Doctors, Inc.

Unnecessary or inappropriately-used medical tests don't only waste time, money and resources: they can harm patients by delaying or denying a correct diagnosis. Here are four action steps doctors can take to avoid inappropriate testing:

4 Ways for Doctors to Avoid Inappropriate Testing from Best Doctors

 Eric Glazer  Vice President  Physician Engagement and Social Media  Best Doctors, Inc.

At the recent Diagnostic Error in Medicine Conference (DEM, held at Johns Hopkins, Nov. 11-15), Dr. Jodi Segal summarized the problem of the overuse of diagnostic tests frankly, “If a test doesn’t influence decisions, it’s a waste.”

That may sound like a sweeping statement, but with reports indicating that the healthcare system spends $750 billion a year in avoidable costs, perhaps it’s an ethos the system should consider adopting. Unnecessary testing doesn’t just burden a healthcare system already saddled with prohibitive costs, but can deny a timely resolution of an accurate diagnosis, causing real harm to the patients who most need care.

Changing any system starts with understanding the “whys.” It can’t be assumed that the majority of doctors endorse a system of waste and inefficiency, nor are they ignorant of it. The real reasons the practice of unnecessary testing persists reflect that most doctors are not perpetuating the system, but mired in it.

Liability

It’s generally assumed that the “CYA” strategy is the largest contributor to the over-testing problem. And really, it’s a fair assumption. A litigious patient is a scary prospect for a doctor, and a thick paper trail of tests makes many feel they have insured themselves against a lawsuit, should their competence in handling a case ever come into question.

Patient Requests

As Dr. Adam Finkelstein, Director of Interventional Oncology at Swedish Covenant Hospital, noted in a previous post, patients often view medical tests as a more thorough level of care, proof that their physician is carefully considering their problem. In the age of the epatient, the “engaged” are not always the “educated,” meaning the results of a test a patient requests may have little to no real bearing on their diagnosis or treatment. It’s important for physicians and patients to partner in managing care, with physician encouraging a healthy culture of question-asking and shared decision making.

Income

Even those doctors who wish to change the culture of wasteful testing acknowledge that they are paid (and sometimes quite handsomely) for every test they order. There is no data on the average percentage of income this generates for physicians, and one doesn’t like to assume that any doctor would order an unnecessary test purely for the money, but the fact remains that the extra income is probably appreciated, and not all are enthusiastic to part with it.

Time

Even patients are aware that doctors are notoriously strapped for time. What they might not know is that doctors often find it quicker to order a battery of tests than to talk to a patient or pore over a case to find the cause of the symptoms.

System

The US is famous for a medical community which can supply every detailed test, latest technology or obscure procedure a patient might require: a praiseworthy reputation by any standard. But easy access to a litany of tests has lead to their rote ordering, diluting the pinpoint accuracy that a more focused approach would yield.

Brian Jackson, MD, MS added a great point to this discussion recently DEM, “When you build lots of cancer screening into the system, you get what you ask for: lots of screening, regardless of whether it’s useful.”

Communication is Key

Perhaps, as Paul Epner, MPH, MEd suggested at DEM, the test-reduction movement should focus less on what is going wrong in the system, and more on the development of tools and procedures to help things go right. By shifting the conversation to focus on the appropriate use of tests, the system can develop a framework of steps, algorithms and check-points which will make ordering of appropriate tests the standard operating procedure.

And when in doubt, suggests Dr. Finkelstein, don’t hesitate to consult with a specialist colleague. “If the treating physician would only call my radiology lab and ask me whether a test will be useful, I’d be more than happy to speak to them about their patient.”

Changing this system is a goal physicians can only reach by communicating and working together.