Teaching About Medical Error

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Teach your medical students and residents to identify and avoid four common medical errors made in training.

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Teaching About Medical Error

  1. 1. Teaching About Medical Error Deirdre Bonnycastle May 2009
  2. 2. Objectives <ul><li>Upon completion of this session, you will be </li></ul><ul><li>able to: </li></ul><ul><li>Identify types of medical learner errors </li></ul><ul><li>Name cognitive errors </li></ul><ul><li>Create a strategy for dealing with each type of error. </li></ul>
  3. 3. <ul><li>“ In Canada the number of people who die from </li></ul><ul><li>adverse events in the health care system each </li></ul><ul><li>year has been estimated to be up to 25,000.” </li></ul><ul><li>P. Croskerry </li></ul><ul><li>Dalhousie College of Medicine </li></ul>
  4. 4. <ul><li>“ It may seem a </li></ul><ul><li>strange principle to </li></ul><ul><li>enunciate but the very </li></ul><ul><li>first requirement in a </li></ul><ul><li>hospital is that it </li></ul><ul><li>should do the sick no </li></ul><ul><li>harm.” </li></ul><ul><li>Florence Nightingale </li></ul>
  5. 5. Saskatchewan Girl Case <ul><li>Week One </li></ul><ul><li>21 year old complaining of chest pain and fatigue, </li></ul><ul><li>mild respiratory distress, family doc left without referring </li></ul><ul><li>patients, so went to minor emergency clinic </li></ul><ul><li>upon examination, there is heart arrhythmia </li></ul><ul><li>patient is send to emergency by ambulance </li></ul><ul><li>two hours later, heart is normal </li></ul><ul><li>referred to heart specialist </li></ul><ul><li>told to not work for two weeks </li></ul>
  6. 6. What did the FM and ER not do? <ul><li>At this point what basic </li></ul><ul><li>information is missing and </li></ul><ul><li>crucial to the case? </li></ul>
  7. 7. <ul><li>Two Week Cost </li></ul><ul><li>To Patient </li></ul><ul><ul><li>$300 ambulance </li></ul></ul><ul><ul><li>$1500 lost wages </li></ul></ul><ul><li>To Medicare </li></ul><ul><ul><li>$ FM </li></ul></ul><ul><ul><li>$ ER </li></ul></ul><ul><ul><li>$ Tests </li></ul></ul>
  8. 8. <ul><li>Week Three and Four </li></ul><ul><li>Patient is examined by specialist </li></ul><ul><li>no heart problem identified </li></ul><ul><li>probably stress note on report </li></ul><ul><li>Patient sees original doctor </li></ul><ul><li>no examination </li></ul><ul><li>given anti-stress drugs </li></ul>
  9. 9. <ul><li>Four Week Cost </li></ul><ul><li>To Patient </li></ul><ul><ul><li>$300 ambulance </li></ul></ul><ul><ul><li>$3000 lost wages </li></ul></ul><ul><ul><li>$70 prescription cost </li></ul></ul><ul><li>To Medicare </li></ul><ul><ul><li>$ FM $ Specialist </li></ul></ul><ul><ul><li>$ ER $ FM </li></ul></ul><ul><ul><li>$ Tests </li></ul></ul>
  10. 10. <ul><li>Week Five </li></ul><ul><li>Patient has a temperature of 103, the pain in her </li></ul><ul><li>chest and difficulty breathing is worse. She goes </li></ul><ul><li>to a different doctor </li></ul><ul><ul><li>diagnosis severe pleurisy </li></ul></ul><ul><ul><li>given weekly injection of antibiotics </li></ul></ul><ul><ul><li>suspicion of lung scarring </li></ul></ul><ul><ul><li>told not to return to work for at least three weeks </li></ul></ul>
  11. 11. <ul><li>Final Cost </li></ul><ul><li>To Patient </li></ul><ul><ul><li>$300 ambulance </li></ul></ul><ul><ul><li>$6000 lost wages = stress at home and work </li></ul></ul><ul><ul><li>$70 inappropriate prescription cost </li></ul></ul><ul><li>To Medicare </li></ul><ul><ul><li>$ FM $ Specialist $ Tests $ FM </li></ul></ul><ul><ul><li>$ ER $ FM $ FM $ FM </li></ul></ul><ul><ul><li>$ Tests $ FM $ Antibiotics </li></ul></ul>
  12. 12. <ul><li>Reflect on the errors and </li></ul><ul><li>we will re-examine this </li></ul><ul><li>case later. </li></ul>
  13. 13. Identify types of medical learner errors <ul><li>Incomplete Knowledge </li></ul><ul><li>Poor Technique </li></ul><ul><li>Cognitive Error </li></ul><ul><li>Systemic Error </li></ul>
  14. 14. Name cognitive errors <ul><li>Categories of Cognitive Errors </li></ul><ul><li>Confirmation Bias </li></ul><ul><li>Attribution Errors </li></ul><ul><li>Commission Bias </li></ul><ul><li>Investigation Errors </li></ul><ul><li>For more information, see </li></ul><ul><li>http://blogs.usask.ca/medical_education/archive/2007/05/teaching_about.html </li></ul>
  15. 15. <ul><li>Why is it difficult to give students feedback </li></ul><ul><li>on cognitive errors? </li></ul><ul><li>How might being able to name the type of </li></ul><ul><li>cognitive error help? </li></ul>
  16. 16. This prevalent cultural pattern—discussing knowledge in groups large and small, but applying it as individual practitioners—is perfectly designed to delay the implementation of new knowledge and to produce wide variation in practice. Systemic Error Zen and the Art of Physician Autonomy Maintenance - Reinertsen Ann Intern Med. 2003
  17. 17. <ul><li>Variation adds complexity </li></ul><ul><li>— to the work of nurses, pharmacists, and physicians who share in the care of our patients. </li></ul><ul><li>— a breeding ground for errors </li></ul>
  18. 18. <ul><li>In the initial case, how would you diagnose the </li></ul><ul><li>types of errors? </li></ul>
  19. 19. <ul><li>In the initial case, how would you diagnose the </li></ul><ul><li>types of errors? </li></ul><ul><li>Systemic </li></ul><ul><ul><li>no referral to new physician when old left </li></ul></ul><ul><li>Cognitive </li></ul><ul><ul><li>Confirmation bias -looking only for heart problem </li></ul></ul><ul><ul><li>Attribution errors - female must be stressed </li></ul></ul><ul><ul><li>Investigation errors -not doing a complete examination -allowing heart specialist to diagnose stress (framing effect) </li></ul></ul>
  20. 20. Create a strategy for dealing with each type of error. <ul><li>Knowledge Errors </li></ul><ul><li>How might Illness Scripts assist students to identify gaps </li></ul><ul><li>in their knowledge? </li></ul><ul><li>How might you use the SNAPPS technique to identify </li></ul><ul><li>gaps in knowledge? </li></ul><ul><li>For more information, see </li></ul><ul><li>http://medicaleducation.wetpaint.com/page/Thinking+like+a+Physician </li></ul>
  21. 21. <ul><li>Errors in Technique </li></ul><ul><li>How might errors in technique be monitored? </li></ul><ul><li>What role does checklists play in improving </li></ul><ul><li>technique? </li></ul><ul><li>What other strategies might you implement? </li></ul><ul><li>“ See one, do one, teach one” training ended at Dalhousie more than a decade ago. Today’s Dalhousie residents receive skills training and responsibilities, carefully graduated and monitored over the course of their residencies.” P. Croskerry </li></ul>
  22. 22. <ul><li>Cognitive Error </li></ul><ul><li>How can the 5 minute preceptor assist you to </li></ul><ul><li>identify cognitive errors. </li></ul><ul><li>How might chart reviews help identify errors? </li></ul><ul><li>How else might you build in safeguards in this </li></ul><ul><li>area? </li></ul><ul><li>For more information see </li></ul><ul><li>http://medicaleducation.wetpaint.com/page/Thinking+like+a+Physician </li></ul>
  23. 23. <ul><li>Systemic Error </li></ul><ul><li>How could you help students recognize the </li></ul><ul><li>difference between personal and systemic </li></ul><ul><li>errors? </li></ul><ul><li>How could the teaching of patient advocacy and </li></ul><ul><li>recognition of systemic errors be combined? </li></ul>
  24. 24. Dr. Pat Croskerry’s suggestions <ul><li>Provide detailed descriptions and thorough characterizations of known Cognitive and Affective errors </li></ul><ul><li>Establish forced consideration of alternative possibilities </li></ul><ul><li>Train for a reflective approach to problem-solving </li></ul><ul><li>Develop generic and specific strategies </li></ul><ul><li>Identify specific flaws and biases in thinking and provide directed training to overcome them </li></ul><ul><li>Develop mental rehearsal, “cognitive walkthrough” strategies for specific clinical scenarios </li></ul>
  25. 25. P. Croskerry continued <ul><li>Improve the accuracy of judgments through cognitive aids </li></ul><ul><li>Provide more information about the specific problem </li></ul><ul><li>Provide adequate time for quality decision-making </li></ul><ul><li>Establish clear accountability </li></ul><ul><li>Improve feedback and feed forward </li></ul><ul><li>- Diagnostic Failure: A Cognitive and Affective Approach </li></ul>
  26. 26. Resources online <ul><li>P. Croskerry Diagnostic Failure: A Cognitive and Affective Approach http:// www.ncbi.nlm.nih.gov/books/bv.fcgi?highlight = Croskerry&rid =aps.section.2444 </li></ul><ul><li>Medical Education Blog http://blogs.usask.ca/medical_education/archive/2007/05/teaching_about.html </li></ul><ul><li>26 Reasons What You Think is Right is Wrong </li></ul><ul><li>http://www.blisstree.com/healthbolt/26-reasons-what-you-think-is-right-is-wrong/ </li></ul><ul><li>Cognitive distortion </li></ul><ul><li>http://en.wikipedia.org/wiki/Cognitive_distortion </li></ul>
  27. 27. Print Resources <ul><li>Croskerry, P. (2003) When diagnoses fail , The Canadian Journal of CME: 79-87 </li></ul><ul><li>Crosskerry, P. (2003) The importance of cognitive errors in diagnosis and strategies to minimize them . Academic Medicine: 78(8):775-780 </li></ul><ul><li>Groopman, J. (2007) How doctors think , Houghton Mifflin </li></ul><ul><li>Mazor, K. et all (2005) Teaching and medical errors Medical Education Journal:39:982-990 </li></ul><ul><li>Montgomery, K.(2006) How Doctors Think: Clinical Judgment and the Practice of Medicine, Oxford University Press </li></ul><ul><li>Redelmeir D. (2005) The cognitive psychology of missed diagnoses Annals of Internal Medicine Volume 142 Issue 2 | Pages 115-120 </li></ul>
  28. 28. <ul><li>Thank You </li></ul>

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