Perspective: Stop! Think! Listen! “Cognitive pause” will reduce medical errors

By Charles A. Pilcher MD FACEP
October, 2013

What kind of medical error accounts for most malpractice payments: Surgical mistakes? Overdoses? Obstetrical errors?

No, no and no. The most common cause of paid claims for malpractice is diagnostic error, accounting for 28.6% of claims and 35.2% of payouts, according to a 25 year summary of US malpractice claims by Saber et al. published in BMJ Quality and Safety. Diagnostic errors resulted in death in 41% of the claims, occurred in the outpatient setting 69% of the time, but were more likely to be lethal if the claim was due to an inpatient error (49% IP v. 37% OP.) Average (inflation adjusted) claim was nearly $390,000, and claims totaled $38.8 BILLION over the 25 years of the study.

As one of the study’s authors summarized,  “You can’t get the treatment right if you don’t get the diagnosis right.”

So why do doctors make so many diagnostic errors, and what can we do to improve?

Let’s consider some facts:

  1. Diagnostic error is defined as a diagnosis that is “missed, wrong, or delayed, as detected by some subsequent definitive test or finding.”
  2. Missed diagnoses are 2.7x more common than delayed diagnoses, and 5.5x more common than wrong diagnoses.
  3. Most errors don’t result in harm; in fact, at least 75% of errors are relatively harmless.
  4. Paid claims are a reasonable surrogate marker for the most serious outcomes.
  5. Autopsies reveal about 80,000 missed diagnoses per year, correction of which could have averted death.
  6. There has been an average of only about 4000 claims per year related to diagnostic error.

Doctors are making a lot of mistakes, many resulting in death or serious disability, but their mistakes result in a successful claim in only 1 case in 20, or 5%. Given these statistics, one wonders why physicians complain about being sued so often; the malpractice crisis could be much worse.

So, why all the errors? And what can be done to eliminate them?

Dr. Mark Jaben, writing in EP Monthly, reviews the work of Dr. Robert Wears, a human factors specialist in health policy, and reports that our pre-frontal cortex, our conscious mind, can only manage about 4-9 variables at a time and is easily overwhelmed. “It tries to rationalize the available information into a plausible explanation that fits, but may not be real.” We can, consciously as well as unconsciously, discount facts that don’t fit commonly known patterns. This leads to “cognitive bias,” discussed earlier here and by Dr.Pat Croskerry. Confronting that bias with a “cognitive pause” is the most effective solution according to both Wears and Croskerry.

Most presentations are low risk and straightforward, with few possibilities. Some cases are more complicated, but the path to diagnosis is straightforward. But other cases are complex, with dangerous possibilities and difficult diagnostic pathways. The problem arises when we overlook issues that make a complex case seem straightforward in an attempt to make the facts fit our pre-frontal cortex rather than the other way around. Every doctor has had this experience, usually a “gut feeling.” For the ED physician, it may mean going home to a sleepless night of self-assessment. To calm one’s gut and sleep soundly requires avoiding error by allowing our brain time to properly process the facts available, i.e., by taking a “cognitive pause.”

This involves just that: pausing. Then, reassess:

  1. Ask “What’s the worst thing this could be? What else could these symptoms indicate?”If one must, involve a colleague.
  2. Get a second set of eyes, ears and hands on the patient, perhaps saying something like “I’m thinking of sending this patient home, but am not 100% comfortable about it. Your thoughts?”
  3. Then, when a diagnosis is reached, ask “What’s the most likely reason my diagnosis could be wrong?”
  4. Finally, acknowledge other possibilities and, says Dr. Jaban, “prepare the patient and family for their role after discharge.”

Physicians are not stupid. We just dismiss possibilities because of cognitive biases. We fail to acknowledge the possibility of the PE, the dissecting aorta, the retroperitoneal hematoma, the malignant hyperthermia, the ruptured aneurysm, the spinal epidural abscess, the thyroid storm, the toxidrome, the drug reaction, the brain abscess, the posterior shoulder dislocation, the nerve or tendon laceration, etc., and we actually dismiss information that does not support our biases.

And our bias is usually for the most likely, the most common, the most recent – and unfortunately  – the most benign presentation of a similar situation… and all too often results in a lawsuit.


{ 1 comment… read it below or add one }

Mark Jaben January 25, 2014 at 7:18 PM

Dr, Pilcher,

I just came across this post.
Thanks for including me and the article in EPMonthy I wrote.


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