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Diagnostic error in Medicine
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Diagnostic error in Medicine

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Cognitive bias in clinical reasoning

Cognitive bias in clinical reasoning

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  • 1. Improving Diagnosis
    • Cognitive bias
    • Dr.Lorenzo Alonso
    • Foro Osler: www.foro-osler.com
  • 2. Adverse events: 3,7% : 14% deaths 27% malpractice: 75% diagnostic problem.
  • 3. Most common medical errors
  • 4. Error: ¿Why? ERROR System -Work place -Communicatión -Alerts
    • Individual
    • fatigue, strees,..
    • reasoning
    • experience
    • metacognition
  • 5. System and Diagnosis An 35 y/o man went to ED Referring back pain and paraparesia He went twice to the ED. No one asked.. And couldn,t retrieve medical record At that moment was impossible to track a diagnosis of melanoma two years before Doctor´s mind: a young Person can,t have An important disease SYSTEM Cognitive
  • 6. JAMA Volume 301(10) March 11, 2009 Copyright 2009 by the American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use. American Medical Association, 515 N. State St, Chicago, IL 60610. ISSN: 0098-7484
  • 7. Diagnostic errors: Definition
    • Diagnostic never made.
    • Wrong Diagnostic.
    • Late Diagnostic.
  • 8. Diagnostic error compound
  • 9. More automatic: More experience More analysis Slower Less experience Wrong mental reasoning Lack of Information. Rethinking Two Systems of reasoning (Croskerry)
  • 10. Examples of Cognitive errors (heuristics) Next cartoons extracted from: Sox. Clinical Decision Making. Butterworth-Heineman 1988.
  • 11. Representation heuristics Endocrinologist think About Cushing in a patient with high BP and hirsutism (non prevalent)
  • 12. Availability The intern saw two Splenic abscess in the previous rotation. Now he thinks that there is another one in front Of him.
  • 13. Premature closing I don,t have the biopsy but anyway, he just came with fever.
  • 14. Overconfidence
  • 15. Framing: to put labels on people
  • 16.  
  • 17. Case 1
    • A patient with a diagnosis of CPOD started with pain and shock during the night. The Hemoglobin levels were around 14. No one thought about bleeding: but he was polycitemic and his previous Hemoglobin levels were over 18..
  • 18. Retroperitoneal Hematoma Hb 13/5/08 19 18/05 17,5 19/05 16,5 21/05 15 22/05/10 14,5 System Failure:”: Communicatión Organizatión informatión
  • 19. Case 2
    • An old man went to the ED after a fall. At the hand recors some doctor wrote: right arm thrombosis
    • Next day the right arm was paretic.
  • 20. Pancoast tumor : 5% lung cancer Horner Syndrom: 14-50% of cases. Framing : old people felt down .. Because they felt down Premature closing : no one examine the information about the previous diagnosis.
  • 21. Recipe to improve diagnostic abilities
    • Common sense
    • Method
    • Study
    • Teamwork
    • Metacognition: to know how we think.
  • 22. Fish bone diagram to study the systems aspects related to diagnosis FAILURE TEAM Communicatión Coordinatión Training PROCESS Not specified Lack of material No supervisión Bad asignament Wrong test ROLES Wrong evaluation of urgency Complications No alerts Inefficient summary of data COGNITIVE COMPOUND
  • 23. (Checklist) Dr. M. Graber
  • 24. IMPROVEMENT AND CHANGE IS POSSIBLE