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Patient Safety and Quality Initiatives

Understanding Errors in Medicine

Diagnostic Errors  
  1. 40,000 to 80,000 deaths result from misdiagnosis annually in the United States (MKSAP 16)
  2. Tort claims for diagnostic errors are twice as common as claims for medication errors (MKSAP 16)
  3. Approximately 40% of malpractice payments in 2003 were related to diagnostic errors (MKSAP 16)
  4. Examples: 
    • Missed Diagnosis
      • Pulmonary Nodule 
        • Follow up is not arranged
      • AKI that has resolved 
        • Patient who have had AKI in the past are at risk of CKD 
      • Adrenal Incidentoloma are not noted
    • Delayed Diagnosis
      • LBBB is not recognized as STEMI equivalent 
      • Deconditioning and weakness not recognized on time (affects intervention timing and hence the recovery)
      • Poor nutritional status of the patient is not recognized on time 
      • Not recognizing the gait instability (in elderly or ataxic patients)
        • Often times leads to fall during hospitalization 
    • Wrong Diagnosis 
      • COPD exacerbation is treated like ACS rule out when main presentation is SOB
      • Pneumonia treated like HF (often when Pneumonia leads to MI leading to HF)
      • Osteomyelitis treated like simply cellulitis  
  5. References

  • Diagnostic Errors 
    • Diagnostic Errors type: If it is not in your Differential Diangosis, you will most likely miss the diagnosis. 
      • Heuristics Errors:
        • Availability Heuristic: Recently seen patient rather than most probable diagnosis
        • Anchoring Heuristic: Premature closure of diagnosis
          • Patient with COPD, HF, presents with SOB. Was not taking lasix. Diagnosis of HF exacerbation was made. In-fact patient had COPD exacerbation
            • Due to lack of physician exam: Chest Expansion, Air movement (relying only on presence of absence of wheeze for diagnosis of COPD)
            • Using Baysian Theory:
              • Using pretest probability of a diagnosis to a post-test probability of a diagnosis. Helps you avoid errors just based on one clinical findings
                • Work up for elevated Troponin is a perfect example. All elevated Troponin are not ACS. 
          • Presentation for Back Pain: Staph Bacteremia, and not a slip disk 
        • Representative Heuristics: Fits certain pattern
      • Not completing a differential diagnosis including "worst-case scenario"
        • Headache in a patient with recent separation from wife, and other family stressors. Tension headache diagnosis was reached despite the concern that 
      • Utilizing time outs
      • Ask Why: 
        • Patient with COPD or CHF Exacerbation, we do not routinely answer a question why. 
        • DKA: We do ask the question why, but once we find the answer, we do not go far enough to help resolve that question
      • Lack of appropriate Physical Exam
        • SJS skin lesion
        • CHF vs COPD 
      • Not listening to the patient
        • Smiley: In severe Pain: Nec Fas
        • Smalls: Severe tenderness on exam: Nec Fas
        • Presentation for Back Pain: Staph Bacteremia, and not a slip disk 
      • Relying on the not so good test to conclude the diagnosis
        • Headache with Cerebral Vein Thrombosis. Two errors: CTA does not rule that out. MRI should have been ordered. 
      • Incomplete DDx:
        • Secondary headache suspected, but Cerberbal Vein Thrombosis was not in the DDx
Diagnostic Reasoning and Diagnostic Error : ACP 2016 

How do we think? 
  • Pattern Presentation: Personal Pattern Processor 
    • Type 1 Reasoning: Shingels 
    • Type 2 Reasoning: Active analytical reasoning. Eg. Ocular melanoma causing Jaundice 
      • With more clinical practice, Type 2 reasoning changes to Type 1 reasoning 
    • Expert problem solver 
      • Content specificity (GI vs Derm lesions)
      • Context specificity : This matters. 
        • Derailed by content specificity 
        • Individual factors matters: 
        • Environment matters 
          • Loud Busy ED vs Quiet slow ED 
          • Time to see patient
          • Patient factors 
Diagnostic Errors:
  • No Fault (7%) 
    • Patient related error 
    • Example: Cocaine uses, BZD users, 
  • System related errors (19%) 
    • Technical Failures: 
      • Faulty test or Data 
    • Organizational Failures
      • Poor EMR
      • Inadequate supervision of trainees
      • Poor communication 
      • Overwhelmed clinicians
  • Cognitive errors (28%)
    • Faulty Knowledge: If not in DDx, you will not make a diagnosis
    • Faulty Data Gathering
      • Failure to ask

      • Failure to examine
        • Breast cancer 
      • Prior records 
    • Faulty synthesis
      • Premature closure 
      • Misjudging the importance of a finding 
        • CT abdomen shows no appendicitis 
      • Faulty context generation : Takes time and effort 
    • Affective Error 
      • Metacognitive failure : If subconscious influence is on your thought process by your previous experiences 

8 ways to reduce diagnostic errors: IOM report from 2015 September 

AHRQ funded research in diagnostic error
1. Increase awareness / experience 
  • Mechanics of diagnostic reasoning
  • Common traps / biases
  • Being skeptical of own / others
2. Improving Intuitutive reasoning 
  • Feedback on diagnostic reasoning : Unlike feedback on A1C, LDL etc
  • Feedback needs to be on good, and bad, routine, remarkable, boring, noteworthy 
  • Coached 
3. Improving analytical reasoning
  • Recognize your risk of bias and make your self think twice
  • Diagnostic time outs
  • Check List
    • Presentation check list (eg. for Chest Pain)
    • General diagnostic check list (complete history, physical exam)
    • Take time to pause and reflect
    • SAFER
      • Serious Diagnosis
      • Alternative Diagnosis
      • Feeling affecting thinking
      • Extraneous data .. is it really extraneous..WBC? 
      • Reasons for why this happened? 
    • Be a skeptic?
  • Bayesian analysis 
4. Improve the context 
  • Radiology rounds?
  • Pathology rounds ?
  • Talking to the PCP?
  • Discussing patient with consultants instead of waiting for the note?
  • Number of patients you see?
  • Improving the atmosphere? 
As a diagnosticians we need

Time with patients
Time to review
Time to think

Medication Errors

  1. Between 500,000 and 1.5 million preventable adverse drug events occur each year in the United States, with an estimated 1 medication error daily for each hospitalized patient. (MKSAP 16)
  2. Examples: 
    1. Drug interactions 
    2. Dose adjustment in impaired kidney or liver function or in elderly (MKSAP 16)
    3. Medications are prescribed, but patient does not receive it (eg. Antibiotics)
    4. Medications are prescribed at wrong dose at wrong times (eg. Anti-hypoglycemics)
    5. DVT and GI prophylaxis are not provided in appropriate patients
      1. GI Bleeding: Not on GI prophylaxis  
    6. Wrong medications are selected
      1. Infectious etiology - Bactrim is given when it is more likely Strep Cellulitis (Bactrim has lower potency for Strep Gp A)
      2. DAPT is not given while conservative management of the UA 
      3. BB and anti-coat are sometime missed during ACS management
    7. Wrong dose and duration of medications 
      1. Infectious etiology
        • Fluconazole for Thrush vs Esophagitis 
        • Vancomycin dose in the presence of bacteremia and previously high MIC 
Transition of Care related Errors 
  1. 20% of patients discharged from the hospital will suffer an adverse event related to medical management within 3 weeks of discharge, 2/3rd  are related to medications. (MKSAP 16)
  2. Medication discrepancies increases 30 day readmission - 14 % vs 6 % in elderly pt: 14 % of elderly patients with medication discrepancies between prescribed outpatient and discharge medications are rehospitalized within 30 days, compared with 6% of those without medication discrepancies. (MKSAP 16)
  3. Pharmacy led med reconciliation - 1 % vs 11 % adverse events at 30 days of discharge: When medication reconciliation efforts are led by pharmacists, the rate of adverse drug events at 30 days is 1% versus 11% in control patients. (MKSAP 16)
  4. Timely follow-up with a PCP after hospital discharge, particularly within 1 month, leads to lower rates of rehospitalization. (MKSAP 16) 
  5. DC Summary does not reach to PCP on timely fashion. And, often, is incomplete. 
  6. Other sources
    1. Patients understanding of the illness is not fully assessed
    2. In such patients, enough attention is not paid to ensure reliable alternatives to ensure medication adherence, timely follow up, rehabilitation
    3. In patients who are unable to do their ADL, dc planning is often incomplete and inaccurate 
  7. Additional Reading

Other preventable harms to the patient during hospitalization
  1. Healthcare associated Infections
    1. CAUTI due to unnecessary use of Urinary Cathetor 
    2. IV access related blood stream infection 
      • Fairly good number of PICC lines are unnecessary. Often leads to DVT and Catheter associated infections 
    3. Good Hand Hygiene can prevent many of these situations 
      1. Hand Hygiene (VIDEO) NEJM 2011
      2. WHO Guidelines on Hand Hygiene in Health Care (2009)
      3. CDC Presentation on Hand Hygiene 
  2. Ordering unnecessary tests 
    1. CT Scan in a patients when it is not needed (especially with Contrast)
      • Contrast extravasation can lead to harm 
    2. Ordering MRI when not necessary
      • Delays the MRI on an otherwise appropriate patients causing delayed diagnosis and prolonging the hospital stay 

MEDICAL COST of Various Tests 

Hands off: Safe Transitions, Reducing unnecessary readmissoins
  • Some reports mentions that 70 % readmissions are preventable 
  • PCP not being aware is the major risk factor for readmission
    • Verbal communication is the Key
    • (Automated when possible) Checklist or Computer generated discharge 
    • Majority of the process are Swiss Cheese Model 
  • TOC Model
    • Transition Care Model: Mary Naylor: 3 nth follow up by Nurse to home; 1000 / pt
    • Care Transitions Model : Erick Coleman: Home visit by layperson over 30 days: 200 / pt
    • Project BOOST: SHM;  Checklist. 7 points (7 P - ... Cost Minimal
    • Project Re-engineered Discharge (RED) : Boston University - Muticomponent - unclear cost 
  • Issues of financing care coordinators 
  • Advantages / Disadvantages of Hospitalists: Econonmis of specialization 
    • Advantage:
      • Expertise in in-patient care
    • Disadvantage:
      • Loss of Dr-Pt care
    • Balancing this is the key 
  • What can be done
    • Identify the most common readmissions and focus the effort on such patient 
  • Emerging Models
    • Comprehensive Care Model
      • See highly complex patients only
      • AM in hospital
      • PM in clinic
      • Much smaller patient panel due to the complexity of patients 
      • Expected hospital stay / year > 10 days 
      • Results: CCP Panel: 200 patients; 3-4 inpatients 
Top 10 Medication Errors 

  • Quinolones
    • Peripheral Neuropathy 
    • Tendon Rupture in shoulder, hand, and achilles tendon
    • Risk Factors: On steroids, and quinolines in older patients 
    • Possible associated with Aortic Disease 
    • Collagen associated Adverse events 
      • Tendon Rupture
      • Retinal Detachments ? 
      • Aortic Aneurysm 
    • Delirium
    • Arrythmia in  a patient with QTc prolongation 
    • Hence: Not indicated for acute bacterial sinusitis, uncomplicated UTI, 
  • Sitaglipitin (DPP4 inhibitors)
    • Polyarthropathy with DPP4 inhibitors 
    • 33 cases identified related to this ; 10 requiring hospitalization 
    • All pain resolved on stopping DPP4 inhibitors
  • Zolpidem 
    • Non AD (OR of 1.33) , Especially when it is due to use of higher doses use
      • Unclear if those patients who were using higher doses also had worse insomnia that may have contributed to insomnia
    • BZD and few others Hypnotic Drugs increase Mortality but was not seen in case of Zolpidem 
    • Increased risk of fall was seen with Zolpidem 
  • NSAIDs and MI 
    • Denmark
    • HR of death with NSAIDS 1.59 at 1 yr
    • FDA has sternghted the warning of CV risk with NSAIDs
    • Increased risk of HF: especially with longer acting NSADs
  • PPI 
    • Risk of CKD
      • JAMA 2016
      • HR of 1.5
      • BID use associated with higher risk 
    • Risk of Dementia ? 
      • HR of 1.4
    • Decreased Ca absorption 
    • Decreased Iron absorption
    • Increased fracture risk 
    • Decreased thyroid absorption
    • Decrease Magneusium absorption
    • Poor B12 absorption
    • Increased risk of C diff and recurrent C diff
  • SGLT 2 inhibitors
    • Risk of euglycemic ketoacidosis (likely due to decreased Insulin production due to low glucose, causing relative hypoinsulinemia)
  • Statin
    • Statin Myalgia more prevalent in patients with Vit D deficiency
      • N Am J Med Sci 2015, On giving high dose Vit D to level > 50 , lead to 95 % patients free of myalgia 
    • Rhabdomyolysis (rare:: 0.01%)
    • Liver failure (0.0001%)
    • Myalgias 5-18 %
      • Check CK, TSH, VItamin D
      • Stop and when stops resolve, restart at lower dose 
      • If recurrent, Try Flucastatin or low dose rosuvastatin
      • If persistent, try ezetemibee
    • Cataracts?
    • Diabetes 
      • J Gen Internal Med 2015 30 (11)
      • Diabetes Care 2014; 37; S14-S80
      • 1 new case per every 255 patients
    • Cognitive impairment
  • CoQ10
    • Does not work for muscle pain or CK levels (Mayo Clinic Proc)
  • SSRI 
    • Hyponatremia is a risk in a patient with
      • Older age
      • Female
      • Concomitant diuretic use makes risk much higher 
      • Low body weight 
  • Hyponatremia
    • HCTZ
    • SSRI
    • SNRI
    • NSAIDS
    • MDMA (ecstasy)
    • Hyperkalemia occurs, with increased risk of Sudden Cardiac Death
    • Much higher risk if on ACEI / ARB
  • Antibiotics and increased risk of SCD
    • TRM/Sulfa
    • Quinolones
    • Azithromycin
  • Drug interaction 
    • Clarithromycin and Statin, Gemfibrozil,
  • Increased Statin Toxicity
    • Fibrates (15 X)
    • Azoles antifungals
    • Amiodarone
    • Erythromycin / Clarithromycin (not azithromycin)
    • Protease Inhibitors
    • Verapamil / Diltiazem (less with amlodipine / nefedipine except with simva)
    • Least DI with Rosuva and Prava, mot with Simvastatin, and lovastatin
    • If taking concurrently, space in time may help 
  • Warfarin
    • Most severe
      • TMP / Sulfa
      • Amiodarone
    • Azinthromycin, Levofloxacin, TMP/SMX all increased INR 

desh bandhu Nepal,
Nov 21, 2016, 6:11 AM