Medical Malpractice Bulletin – December, 2016

In this issue:

Perspective: Pearls from the “Diagnostic Errors in Medicine” conference
Charles A. Pilcher MD FACEP

By far the best presentation I attended at at the 2016 “Diagnostic Errors in Medicine” conference in Los Angeles last month was the 3 hour seminar hosted by PIAA (formerly Physicians Insurance Association of America). Over 300 physicians, educators, insurance companies executives, risk managers, quality & safety specialists, patient advocates and medical society representatives meet annually, working together through the Society to Improve Diagnosis in Medicine to reduce the incidence of diagnostic error in medical practice. Readers of the Medical Malpractice Bulletin will find many issues familiar to med mal attorneys in the comments made by the distinguished members of the panel discussion on “Improving Diagnosis and Patient Outcomes.” Read the “pearls” here ->

Do blind radiologists miss important findings?

Semelka et al. published a study of 31 radiologists blinded to the interpretation by 4 plaintiff expert radiologists who testified in a lawsuit that missing 3 findings on a CT scan, one of them critical, was below the standard of care. The study replicated a typical radiologist’s caseload. Of the 3 findings found by the plaintiff’s experts, 1 was missed by 12 of the 31 blinded radiologists; the other 2 findings (one of which was the “critical finding” on which the lawsuit was based) were missed by all 31 of the study’s blinded radiologists. The impact of hindsight bias is obvious. The authors recommend that in order to make valid interpretations of the standard of care for radiologists, diagnostic imaging studies that are critical to a lawsuit be evaluated by a panel of blinded radiologists before ascribing a “miss” to negligence.

Diagnostic Error for Dummies: The “dirty dozen” ways to avoid mistakes
In an article titled “Stop and think — Return visits offer another chance,” the Canadian Medical Protective Association has neatly summarized essentially all of the possible ways to avoid a lawsuit related to diagnostic error following a return visit to a physician’s office, clinic or the ER. (Editior’s Note: Most items on the list sound as if they came from depositions of defendant physicians. If you can recall a lawsuit for diagnostic error that was not the result of missing one of the opportunities described here, please contact me.) Here’s the CMPA list:

  1. Taking the time to pause and reflect on the differential diagnosis, being careful to consider possibilities that may be life-threatening.
  2. Before establishing a diagnosis, reading all key elements of the patient’s medical record including earlier entries, test results, and consult reports.
  3. Using algorithms or clinical practice guidelines to assist clinical judgment in determining the need for further testing.
  4. Creating a process to facilitate the review and follow-up of test results.
  5. Avoiding reliance on a colleague’s earlier diagnostic impression when assessing a patient.
  6. Being careful to keep an open mind when patients’ explain the source of their symptoms.
  7. Re-evaluating the diagnostic assumption and repeating the physical examination with vital signs, when the patient returns with the same or worsening symptoms.
  8. Reflecting on whether cognitive biases such as anchoring or diagnostic momentum are influencing the ability to arrive at a final diagnosis.
  9. Recognize that patients may be frustrated or angry, and so effective communication will be important to obtain new information. Consulting a colleague may be helpful.
  10. Ensuring clear written and verbal instructions are provided to patients or their families.
  11. Ensuring documentation reflects a thorough assessment, history taking, and the rationale for the differential diagnosis.
  12. Documenting discharge instructions and relevant discussions.

Is “medical error” really the third leading cause of death in the US

In May the BMJ published a “study” by Makary and Daniel that was picked up by the media (with encouragement from the lead author). The resulting headlines likely scared more people to death than the alleged “medical errors.” Makary’s gross over-estimate of death from medical error stemmed from his acceptance of multiple loose definitions of “medical error” used in the 4 previously published articles for his op-ed piece, i.e., anything that happens to a patient that was not planned, e.g., an allergic reaction to a prescribed medication, a post-op wound infection, a bile leak during cholecystectomy or post-op VTE despite appropriate prophylaxis or bleeding during vascular surgery. The article was rejected for publication by NEJM, roundly denounced by over 50 BMJ readers and criticized by other authors. However, Makary makes one valid point: When a medical error actually does occur, our coding taxonomy both in medical records and on death certificates should be able to record it to establish a true rate of error and improve patient safety.

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