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Errors in the diagnostic process

Errors in the diagnostic process. Hierarchy of Qualities in Medicine Frequency of diagnostic Errors Judgment under Uncertainty: Heuristics and Biases The Voytovich Solution. Click to View Presentation. Hierarchy of Qualties in Medicine From patient‘s point of view. Patient Satisfaction.

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Errors in the diagnostic process

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  1. Errors in the diagnostic process • Hierarchy of Qualities in Medicine • Frequency of diagnostic Errors • Judgment under Uncertainty: Heuristics and Biases • The Voytovich Solution Click to View Presentation

  2. Hierarchy of Qualties in MedicineFrom patient‘s point of view Patient Satisfaction Therapeutic Quality Diagnostic Quality

  3. Hierarchy of Qualties in MedicineMedical point of view Patient Satisfaction Therapeutic Quality Diagnostic Quality

  4. Hierarchy of Qualities in Medicine und cognitive Processes Patient Satisfaction Skills Rules TherapeuticQuality Knowledge Diagnostic Quality

  5. Frequency of diagnostic ErrorsFollow-up Autopsy Study Medizinische Klinik USZ 1972-1982-1992-2002Lancet 2000;355:2027-31 • Random Selection of 100 patients in each year • Autopsy Rate above 90% until 1992, in the year 2002 Reduction to 53%, complete Autopsy • Classification of diagnostic Errors according to Goldman

  6. Classification of diagnostic errors Goldman et al NEJM 1983:380: 1000-05 • Major diagnostic Errors • Class I: Knowledge of correct Diagnosis would have led to Survival • Class II: Knowledge of correct Diagnosis would not have affected Survival (too ill, no Treatment available) • Minor diagnostic Errors • Class III: Missed Diagnosis but not cause of Death • Class IV: Occult, clinically not diagnosable Entity of epidemiological Interest eg Gallstones

  7. Major Diagnostic Errors 1972-2002

  8. Minor Diagnostic Errors 1972-2002

  9. Class I+II vs. Class III+IV

  10. Correct Diagnosis 1972-2002

  11. Autopsy Rate and class I Errors over time Kaveh G et al, JAMA 2003: 289:2849-56

  12. Frequency of class I Errors Klasse I Autopsie- Fehler rate • Medizin+ IPS (USZ) 2002 2% 53% • Med-IPS (Mayo-Clinic) 1998-2000 4% 33% • Med-IPS (Paris) 1995-98 10.2% 53% • Med-IPS (Leuven,Belgien) 1996 16% 93% • 32 Spitäler in USA 1984 13% 30% • Medizin (Boston, USA) 1984 12% 40% Arch Int Med 2004:164;389; Mayo Clin Proc 2000:75:562; Ann Thorac Surg 1997:64:380; JAMA1987:258:339; Mayo Clin Proc. 2003;78:947-50. NEJM 1988:318;1249

  13. Autopsy: Gold Standard for clinical Diagnosis? Pelletier et al J Gen Intern Med 1989:4;300-03

  14. Autopsy: Gold standard for clinical diagnosis? Pelletier et al J Gen Intern Med 1989:4;300-03

  15. Judgment under Uncertainty: Heuristics and BiasesTversky and Kahneman Science 1974:185:1124-31 • Representativness • Similarity with „typical“ examples stored in memory • Availability • Recent expierence, painful memory • Adjustment and Anchoring • Stick to early hypotheses despite new information

  16. Cognitive Mechanisms of diagnostic Errors according to A.E. Voytovich* • Omission • Premature Closure • Inadequate Synthesis • Wrong Formulations * J Med Educ 1985:60;302-07

  17. Omission • Most frequent Error • Decreases with Experience Consequences • Delayed or missed Diagnosis

  18. Premature Closure • Independent of Experience • Correlates with Confidence (ie Overconfidence) in Relation to the actual Case • Reflects estimated Frequency of the diagnosed Disease • Consequences • Delayed or missed Diagnosis • Unnecessary Therapies • False Sense of Confidence if Error is not detected

  19. Inadequate Synthesis • Correlates with Experience Consequences • Unnecessary Investigations • Delayed Treatment

  20. Cognitive Mechanisms of diagnostic Errors according to A.E. Voytovich* • Omission • Premature Closure • Inadequate Synthesis • Wrong Formulations * J Med Educ 1985:60;302-07

  21. Lancet 2000:355;2027-31

  22. Major Diagnostic Errors 1972-2002

  23. Sensitivity and Specificity • 1-Sensitivity: Rate of missed Diagnoses (false negative rate) • 1-Specificity: Rate of wrong Diagnoses (false positive rate)

  24. Cardiovascular DiseasesSensitivity and Specificity p = 0.061 p = 0.034 100 97% 90 86% 85% 1972 82% 82% 80 1982 1992 69% 70 60 50 Sensitivität Spezifität

  25. Lancet 2000:355;2027-31

  26. Infectious DiseasesSensitivity and Specificity p = 0.036 ns 100% 100% 99% 100 86% 80 67% 1972 60 1982 1992 40 25% 20 0 Sensitivität Spezifität

  27. Neoplastic DiseasesSensitivity and Specificity ns ns 100 97% 96% 96% 95 92% 89% 1972 90 88% 1982 85 1992 80 75 70 Sensitivität Spezifität

  28. Difficulties in learning from Experience • Lack of Search for and use of disconforming Evidence • Lack of outcome Information • Use of unaided Memory for coding, storing and retrieving outcome Information

  29. Summary and Proposal • Major diagnostic Errors occur despite an ever increasing repertory of diagnostic Procedures • 85% of serious diagnostic Errors can only be detected by Autopsy • Analysis of error mechanism can be helpful in the Discussion and Prevention of diagnostic Errors • Minimum Autopsy rate of 30% along with a yearly Report on diagnostic Errors should be mandatory for Accreditation of medical Clinics

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