Greater awareness of the causes of diagnostic errors can help physicians avoid many of them
Most errors in clinical reasoning are not due to incompetence or a knowledge deficit, but, instead, usually have their origins in inadequate clinical assessments, loss of situational awareness or team communication breakdowns.
“It’s not that people don’t know how to put the puzzle together, it’s that they are not looking at all the pieces of the puzzle,” said Dr. Janet Nuth, an emergency physician and advisor at the Canadian Medical Protective Association (CMPA). Dr. Nuth made her observation as part of a recent educational session hosted by the CMPA, designed to help physicians identify risks associated with diagnostic decision-making and implement practical approaches to prevent patient harm.
The frequency of diagnostic error in all CMPA legal actions is approximately 21 percent, based on an analysis of 17,278 closed case files over a five-year period. Of these cases, 87 percent featured a delayed diagnosis or a misdiagnosis in which experts were critical of the treating physician’s assessment of the patient.
What types of conditions are escaping physicians’ detection in CMPA case files? Surprisingly, said Dr. Nuth, they are not rare disorders. It is much more likely for a common condition to be misdiagnosed or have a delayed diagnosis, such as cancer (particularly breast and colon), fractures, infections and ischemic heart disease.
Physicians work in high-pressure, fast-paced environments. Arriving at the correct diagnosis while contending with numerous complicating factors can be challenging. But maintaining situational awareness is critical, said Dr. Tino Piscione, acting director of CMPA’s Safe Medical Care Learning. He describes it as a cognitive skill that involves:
- Gathering information;
- Understanding the information, including its significance in the context of the situation; and
- Applying that understanding in order to think ahead and anticipate potential complications.
In the simplest terms, situational awareness is keeping an eye on the “big picture,” while managing the individual issues that arise.
But it’s easy to lose situational awareness. Whether it is cognitive overload or the frailty of human thinking, physicians can drift away from methodical approaches to evaluation. For example, a physician may forget to inquire about family history during an assessment.
Situations that raise red flags — such as multiple visits from patients with unresolved concerns over a brief period of time or patients’ condition not following the natural course of presumed illness or patients not responding to treatment as expected — require physicians to revisit their presumptive diagnosis. Failure to assess vital signs when appropriate, continuing abnormalities or worsening vital signs figure prominently in many medical-legal cases.
In fact, the loss of situational awareness — represented by a missed opportunity to stop and reassess the patient from a different perspective — was identified as an issue contributing to missed, wrong or delayed diagnoses in 49 percent of CMPA case files.
Dr. Shirley Lee, a physician advisor at CMPA and an emergency physician, said she recommends thinking about a “working diagnosis” when formulating an initial impression to avoid the pitfalls of anchoring bias. She said the phrase keeps her in an exploratory mindset, making her open to the possibility of alternative diagnoses when new information is discovered or the patient’s condition evolves.
Communication and documentation can help put physicians back on track, said Dr. Piscione. Not only does documentation leave an intellectual footprint of a physician’s reasoning and demonstrate their diligence, it can help a physician identify potential gaps in their assessment. In addition, when the diagnosis is difficult to establish or is uncertain, communicating that fact to the patient helps them understand the importance of follow-up, whether it is for consultations, reassessment visits or further testing. The process of communicating and documenting clinical reasoning and the rationale for decisions all present opportunities for physicians to be more reflective about their approach, he said.
Noting that ineffective team communication is a significant contributor to diagnostic error, Dr. Louise Dion, a senior physician advisor at CMPA, said structured team processes, such as briefings and huddles, force the team to “slow down when it should” at the preparation phase of clinical decision-making.
All health care professionals on the team should feel safe in confirming information or asking questions about the specific patient, the environment, the tasks, or the timing or urgency. “It should be made clear that there is no such thing as a stupid question,” she said. These proactive efforts promote team situational awareness and highlight potential critical situations ahead.
From CMPA’s Files
Percentage of cases with diagnostic error:
75% — Decision-Making
87% — Deficient Clinical Assessment
53% — Team Factors
- Use structured communication tools and techniques.
- Encourage team members to speak up by providing a psychologically safe environment, i.e., “no such thing as a stupid question.”
- Hold regular huddles, team meetings and briefings to leverage the expertise of the team.
- Read all key elements of the patient’s medical record, including earlier entries, test results and consult reports.
- Plan proactively for contingencies by asking, “what if?”
- Engage in reflective practice by asking whether your thinking is subject to bias.
- Slow down and hone awareness.
- Document both negative and positive pertinent findings.
- Use clinical practice guidelines to assist clinical judgment in determining the need for
- Pause to reflect on a differential diagnosis.
- Close the loop on tasks.