IV Jornada. Sp y práctica reflexiva f borrell_pompeu fabra_2011

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Es la conferencia inaugural de la IV Jornada, de Borrell-Carrió. Hizo una revisión muy interesante de como nuestros automatismos mentales pueden poner en riesgo la práctica de un diagnóstico acertado, sobretodo en los casos en los que la primera impresión no es la acertada.

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IV Jornada. Sp y práctica reflexiva f borrell_pompeu fabra_2011

  1. 1. SEGURIDAD CLINICA Y PRACTICA CLINICA REFLEXIVA Francesc Borrell i Carrió.Profesor Titular de MFC, Facultad Medicina, Universidad Barcelona, Departament de Ciències Clíniques. EAP Gavarra. ICS Email.- 12902fbc@comb.cat
  2. 2. CONTENIDOSIntroducción.- Modelo centrado en el paciente. Self awareness.El acto clínico.- Lo que sabemos -Estudios epidemiológicos. -Estudios de performance, (Pacientes Incógnito).Estrategias de mejora. El profesional El sistema. -Prefaseg.
  3. 3. VALORES CLAVE DEL MODELO• AFLORAR: necesidades, perspectiva y valores del paciente.• COMPARTIR: decisiones, comprensión.• CONSTRUIR: una relación empática y sensible (responsiveness).
  4. 4. MODELO CENTRADO EN EL PACIENTE TAREAS EN LA ENTREVISTA.• FASE EXPLORATORIA: – El paciente puede hablar. Ocupación verbal. – Más allá del síntoma aparece la persona: • Creencias, ilusiones, expectativas, miedos…• FASE RESOLUTIVA: – El paciente puede participar: • En la definición de su problema. • En el plan de actuación.
  5. 5. PRACTICA CLINICA REFLEXIVA.• ME OBSERVO: – En el “ahora”, sin idealizarme, escuchando mis emociones que me advierten de peligros.• REFLEXION EN LA ACCION: – Escuchamos y exploramos para crearnos una imagen del paciente. Independencia de criterio. – Integro los datos en la persona: • Terreno biológico, contexto psicosocial.• REFLEXION FUERA DE LA CONSULTA: – Gestión poblacional. Prevención. – Gestión individual: • Pongo al paciente en mi agenda. • Comparto con el equipo.
  6. 6. ¿Aporta algo que no nos aporte el enfoque sistémico? Acciones claras y muchas veces simples. Accountability. Políticas organizacionales.
  7. 7. ESTUDIOS INTERNACIONALES• Leape L, Brennan TA, Laird N, et al. The nature of adverse events in hospitalized patients: results of the Harvard Medical Practice Study II. N Engl J Med. 1991;324:377– 384.• Wilson RM, Harrison BT, Gibberd RW, Hamilton JD. An analysis of the causes of adverse events from the Quality in Australian Health Care Study. Med J Aust. 1999;170:411– 415.• Bhasale A, Miller G, Reid S, Britt HC. Analyzing potential harm in Australian general practice: an incident-monitoring study. Med J Aust. 1998;169:73–76.• Thomas EJ, Studdert DM, Burstin HR, et al. Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care. 2000;38:261–271.• Baker GR, Norton PG, Flintoft V, et al. The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. CMAJ. 2004;170:1678 –1686.• Davis P, Lay-Yee R, Briant R, Ali W, Scott A, Schug S. Adverse events in New Zealand public hospitals II: preventability and clinical context. N Z Med J. 2003;116:U624.
  8. 8. ERROR MEDICO ENEAS 9,3% (525/5.624); IC95%: 8,6% - 10,1% INGRESOS• Toma de datos. • Medicación: 37,4% • Infecciones nosocomiales 25,3%• Diagnósticos. • • Problemas técnicos Diagnóstico 25,0% 2,75%• Tratamiento. APEAS CONSULTAS 11,18‰ (IC95%: 10,52 - 11,85). • Medicación: 48,2%• Seguimiento. • Cuidados 25,7% • Comunicación 24,6% • Diagnóstico 13,1% • Gestión 8,9% • Otros 14,4% IBEAS, (10,5% EA) OTROS.- Jesús María Aranaz Andrés
  9. 9. TOTAL Moderados- gravesEventos 47,7% 30,0%-5,7%adversosrelacionadosconlamedicaciónRAM 59,1% 66,1%evitables
  10. 10. LO QUE NO PUEDE VER EL APEAS• Errores en la comunicación y relación asistencial.• Desacierto diagnóstico o falta de diagnóstico sin consecuencias inmediatas y no percibido por informante.• Omisión de maniobras diagnósticas, terapéuticas o preventivas.• Falta de seguimiento.
  11. 11. INCLUSO CUANDO TENEMOS SISTEMA DE NOTIFICACION CONFIDENCIAL….Muchos errores diagnósticos no se detectan como EA:• “La mayor parte de errores diagnosticos prevenibles no se informan a través de los medios de notificación voluntario”. Fischer G, Fetters MD, Munro AP, Goldman EB. Adverse events in primary care identified from a risk-management database. J Fam Pract. 1997;45:40–46• Ninguno de los errores de diagnóstico que revelaron los residentes había sido informado a las base de datos.• Weingart S, Ship A, Aronson M. Confidential clinical-reported surveillance of adverse events among medical inpatients. J Gen Intern Med. 2000;15:470–477.
  12. 12. “NEGACIONISMO”• El 28% eran “negadores”(I.C95%: 22.34-34.26),• 67 % “perceptivos” (I.C95%: 60.79-73.23),• 7.4% “hiperperceptivos” (I.C95%: 4.41-11.44),• 6% “locus interno”(I.C95%: 3.34-9.91),• 23.4 % hiperseguros(I.C95%: 18.14-29.22).• Se informó sobre 10.6 acontecimientos adversos/año/profesional, sobretodo eventos adversos de fármacos (37%)(I.C95%: 35.36-39.15) , y retraso diagnóstico en patología neoplásica (33%) (I.C95%: 31.16-34.85). Borrell F, Paez C, Suñol R, Orrego C, Gil N, Marti M Errores clínicos y eventos adversos: p ercepción de los médicos de atención primaria. Aten Primaria 2006; 38(1):25-32Solo 1% admite públicamente haberse equivocado en el último año. Berner ES, Graber ML Overconfidence as a Cause of Diagnostic Error in Medicine The American Journal of Medicine (2008) Vol 121 (5A), S2–S23
  13. 13. Graber ML. 5 años, 3 centros, 100 casos de error diagnóstico. • *Sistémicos: fallos tecnológicos, mala organización. 65% • *No error: falta colaboración paciente, presentación atípica 44% • *Cognitivos: falta de conocimiento, toma de datos, sintesis de datos. 74% • Dentro de los cognitivos: • Falta de conocimientos 11 ocasiones • Falta de datos tomados del paciente: 45 • Falta de procesamiento adecuado de la información 159 • Falta de verificación 106 • CAUSA PROFUNDA: CIERRE PRECIPITADO Graber ML, Franklin N, Gordon RR. Diagnostic error in internal medicine. Arch Intern Med. 2005;165:1493–1499.
  14. 14. “Error diagnóstico”• “Diagnostic error”: retraso no intencionado (existía suficiente información previa), equivocado(otro diagnóstico se realizó antes del correcto), o no presente (no se realizó diagnóstico), desde la perspectiva de una información final mas definitiva. Graber ML, Franklin N, Gordon RR. Diagnostic error in internal medicine. Arch Intern Med. 2005;165:1493–1499.
  15. 15. Errores por especialidades• -Especialidades perceptivas: radiologia 5%, A Patologica <5%, Dermatologia 11%.• -Especialidades médicas 10-15%.• -Superior en urgencias y entornos de alta densidad de decisiones. Berner ES, Graber ML Overconfidence as a Cause of Diagnostic Error in Medicine The American Journal of Medicine (2008) Vol 121 (5A), S2–S23
  16. 16. Errores por patologiasEntidad % CometariosAneurisma Aorta 35% Precordialgias, 1era evaluacion sin diag.Hemorragia subaracn 30% 1era. evaluacion sin diagnósticoMamografia Ca mama 21% 1era. lectura con errorT. Bipolar 69% Diagnóstico inicial incorrectoArtr. Psoriásica 39% 1era vista reumatólogo no diagn.Diabetes Mellitus 18% No consta diagnóstico en HCLectura Radiografias 30% Errores cuando leídas en consulta (no radiólogo).
  17. 17. EL ENFOQUE SISTEMICO DEBE AFRONTAR UNA REALIDAD INCOMODALA PERSONA ES PARTE DEL SISTEMA
  18. 18. EL MEDICO COMO CAJA NEGRAdatos Decisiones Actos
  19. 19. EL MEDICO COMO CAJA NEGRA • FALIBILIDAD. • MEJOR EFICIENCIA. – Curva de rendimiento. • MANTENIMIENTO • “OXIDACION”¡SI AL MENOS SE NOS CONSIDERARA COMO UNA MÁQUINA!
  20. 20. ¿COMO APROXIMARNOS A ESTA INCOMODA REALIDAD? ESTUDIOS DE LABORATORIO ESTUDIOS EN LAS CONDICIONES NATURALES DEL PROFESIONAL
  21. 21. ESTUDIOS NIVEL 4 PIRAMIDE DE MILLER
  22. 22. PACIENTE ESTANDARIZADO Y ENMASCARADOPREPARACION VISITA CON AUDIOGRABACION ENMASCARAMIENTO RECUPERACION SALA ESPERA DE DATOS – ENCUESTA
  23. 23. ESTUDIOS ESPAÑOLES• Suñol R: Correlación entre los procesos y los resultados de la Entrevista Clínica: su aplicación a los programas de calidad en Atención Primaria. Tesis Doctoral, Universidad Autónoma de Barcelona. Barcelona, 1992• Prados Castillejo, JA. Distorsión en las Técnicas Comunicacionales (Entrevista Clínica) en las consultas de Demanda de Atención Primaria. Tesis Doctoral. Universidad de Córdoba. Facultad de Medicina. Departamento de Medicina. Córdoba 1996 .• Barragán N, Violan C, Martín Cantera C, Ferrer-Vidal D, González-Algas J. Diseño de un método para la evaluación de la competencia clínica en atención primaria Aten Primaria. 2000 Nov 30;26(9):590-4.
  24. 24. ESTUDIOS ESPAÑOLES• Borrell F.,Fontova B, Muñoz E, Prados JA, Pedregal M, Peguero E. Physician s ability to find a physical sign (hepatomegaly). European Journal Gen Pract 2011.• Llor C, Cots JM. The sale of antibiotics without prescription in pharmacies in Catalonia, Spain.Clin Infect Dis. 2009 May 15;48(10):1345-9.
  25. 25. ESTUDIOS INTERNACIONALES• 46 TRABAJOS, 24 EN LOS ÚLTIMOS 5 AÑOS.1.-McLeod PJ, et al. Use of standardized patients to assess between-physician variations in resource utilization JAMA. 1997 Oct 8;278(14):1164-82.-Dresselhaus TR, et al The ethical problem of false positives: a prospective evaluation of physician reporting in the medical record J Med Ethics. 2002 Oct;28(5):291-43.- Rethans jj, Sturmans F, Drop R, Van der Vleuten c, Hobus P. Does competence of general practitioners predict their performance? Comparison between examination setting and actual practices BMJ 1991 Nov 30;303(6814):13774.-.- Suñol R: Correlación entre los procesos y los resultados de la Entrevista Clínica: su aplicación a los programas de calidad en Atención Primaria. Tesis Doctoral, Universidad Autónoma de Barcelona. Barcelona, 19925.- Borrell F.,Fontova B, Muñoz E, Prados JA, Pedregal M, Peguero E. Physician s ability to find a physical sign (hepatomegaly). European J Gen Pract 2011.6.-Franz CE, Epstein R, Miller KN, Brown A, Song J, Feldman M, Franks P, Kelly-Reif S, Kravitz RL. Caught in the act? Prevalence, predictors, and consequences of physician detection of unannounced standardized patients. Health Serv R7.-Gallagher TH, Lo B, Chesney M, Christensen K. How do physicians respond to patients requests for costly, unindicated services?J Gen Intern Med. 1997 Nov;12(11):663-8.8.-Kravitz RL, Epstein RM, Feldman MD, Franz CE, Azari R, Wilkes MS, Hinton L, Franks P. Influence of patients requests for direct-to-consumer advertised antidepressants: a randomized controlled trial.JAMA. 2005 Apr 27;293(16):1995-2002.9.-Brown JA, Abelson J, Woodward CA, Hutchison B, Norman G. Fielding standardized patients in primary care settings: lessons from a study using unannounced standardized patients to assess preventive care practices. Int J Qual Hea10.-Zabar S, Ark T, Gillespie C, Hsieh A, Kalet A, Kachur E, Manko J, Regan L. Can unannounced standardized patients assess professionalism and communication skills in the emergency department? Acad Emerg Med. 2009 Sep;16(9):911.-Epstein RM, Levenkron JC, Frarey L, Thompson J, Anderson K, Franks P. Improving physicians HIV risk-assessment skills using announced and unannounced standardized patients. J Gen Intern Med. 2001 Mar;16(3):17612.-Srinivasan M, Franks P, Meredith LS, Fiscella K, Epstein RM, Kravitz RL. Connoisseurs of care? Unannounced standardized patients ratings of physicians. Med Care. 2006 Dec;44(12):1092-8.13.- Fiscella K, Franks P, Srinivasan M, Kravitz RL, Epstein R. Ratings of physician communication by real and standardized patients. Ann Fam Med. 2007 Mar-Apr;5(2):151-8.14.- Ozuah PO, Reznik M. Residents asthma communication skills in announced versus unannounced standardized patient exercises.Ambul Pediatr. 2007 Nov-Dec;7(6):445-8.15.- Barragán N, Violan C, Martín Cantera C, Ferrer-Vidal D, González-Algas J. Diseño de un método para la evaluación de la competencia clínica en atención primaria Aten Primaria. 2000 Nov 30;26(9):590-4.16.- Prados Castillejo, JA. Distorsión en las Técnicas Comunicacionales (Entrevista Clínica) en las consultas de Demanda de Atención Primaria. Tesis Doctoral. Universidad de Córdoba. Facultad de Medicina. Departamento de Medicina.17.-Krane NK, Anderson D, Lazarus CJ, Termini M, Bowdish B, Chauvin S, Fonseca V. Physician practice behavior and practice guidelines: using unannounced standardized patients to gather data.J Gen Intern Med. 2009 Jan;24(1):53-6. Epub 2008 Oct 31.18.- Feldman MD, Franks P, Duberstein PR, Vannoy S, Epstein R, Kravitz RL. Lets not talk about it: suicide inquiry in primary care.Ann Fam Med. 2007 Sep-Oct;5(5):412-8.19. Epstein RM, Shields CG, Meldrum SC, Fiscella K, Carroll J, Carney PA, Duberstein PR. Physicians responses to patients medically unexplained symptoms. Psychosom Med. 2006 Mar-Apr;68(2):269-76.20. Seaburn DB, Morse D, McDaniel SH, Beckman H, Silberman J, Epstein R. Physician responses to ambiguous patient symptoms. J Gen Intern Med. 2005 Jun;20(6):525-30.21.- Peabody JW, Luck J, Jain S, Bertenthal D, Glassman P. Assessing the accuracy of administrative data in health information systems. Med Care. 2004 Nov;42(11):1066-72.22. Carney PA, Dietrich AJ, Eliassen MS, Owen M, Badger LW. Recognizing and managing depression in primary care: a standardized patient study. J Fam Pract. 1999 Dec;48(12):965-72.23.-Kravitz RL, Franks P, Feldman M, Meredith LS, Hinton L, Franz C, Duberstein P, Epstein RM. What drives referral from primary care physicians to mental health specialists? A randomized trial using actors portraying depressive sym24.- Woodward CA, Hutchison B, Norman GR, Brown JA, Abelson J.What factors influence primary care physicians charges for their services? An exploratory study using standardized patients. CMAJ. 1998 Jan 27;158(2):197-202.25.- Rethans JJ, Saebu L. Do general practitioners act consistently in real practice when they meet the same patient twice? Examination of intradoctor variation using standardised (simulated) patients. BMJ. 1997 Apr 19;314(7088):1
  26. 26. RESUMEN DE ESTOS TRABAJOS Fiabilidad, validez, detección o sospecha del paciente, factibilidad y satisfacción del profesional.
  27. 27. ASPECTOS GENERALES• PSI mejor método para analizar acto asistencial.• Competencia y Performance son diferentes.• Historia Clínica (notas clínicas) poco fiables para juzgar calidad.• El Paciente Problema inhibe habilidades de anamnesis.• Gran esfuerzo para gestionar el tiempo.• Las expectativas del paciente marcan diferentes “finales”.
  28. 28. SITUEMOS ESTOS HALLAZGOS EN UN MODELOBorrell-Carrió F. Epstein RPreventing errors in clinical practice: a call for self-awarenessAnn Fam Med 2004;2(4):310-316.
  29. 29. ¿COMO LLEGAMOS A UN DIAGNÓSTICO?SITUACIÓN- PRIMERASESTÍMULAR: HIPÒTESISINTENCIONALIDAD REENCUADRE CONDUCTAS VERIFICACIÓN COLAPSO COGNITIVO CONDICIONES DE SUFICIENCIA “OFERTA” QUE HAREMOS AL PACIENTE
  30. 30. CAPACIDAD VERSUS DISPOSICION.• CAPACIDAD: COMPETENCIA, NIVEL 3. “GENOTIPO”.• DISPOSICIÓN: PERFORMANCE, NIVEL 4. “FENOTIPO”. FACTORES RESTRICTIVOS• CAPACIDAD : LO QUE SOY CAPAZ DE HACER• PERCEPTIVA, AHORA Y AQUÍ• COGNITIVA,• CONDUCTUAL.
  31. 31. DISPOSICIONES AFECTIVAS, ACTITUDINALES/ CARACTERIALES Y COGNITIVAS.• AFECTIVAS:• ESTADOS TRANSITORIOS: cansancio, ruido, calor o frío, hiperestimulación sensorial, deprivación sueño, etc.• SITUACION CLINICA: agresividad, contra- transferencia, atribuciones…• SITUACION AFECTIVA ENDOGENA: trastorno del humor, de ansiedad, trastornos ciclotímicos, circadianos, etc.Pat Croskerry, Allan A Abbass, Albert W Wu How doctors feel: aff ective issues inpatients’ safetyThe Lancet Vol 372 October 4, 2008 1205-6
  32. 32. DISPOSICIONES AFECTIVAS, ACTITUDINALES/ CARACTERIALES Y COGNITIVAS.• ACTITUDINALES / CARACTERIALES:• Rasgos polares que limitan o sesgan la percepción y o el razonamiento.-• -Profesional frío, distante y “muy técnico” // hipersensible al sufrimiento ajeno, complaciente, busca “agradar”.• -Profesional inseguro- reduccionista- evitador // hiperseguro, resolutivo.• Rasgos que limitan o sesgan el razonamiento.-• -Profesional altamente atributivo, culpabilizador, testarudo.• -Profesional altamente defensivo, autoritario o paternalista• -Profesional irónico- egodistónico- solipsista• -Profesional «ansioso-asegurador», temeroso, obsesivo. Borrell-Carrio F, Epstein RM, Pardell H.. Profesionalidad y professionalism: Fundamentos, contenidos, praxis y docencia Med Clin (Barc). 2006;127(9):337-42
  33. 33. DISPOSICIONES AFECTIVAS, ACTITUDINALES/ CARACTERIALES Y COGNITIVAS.• COGNITIVAS:• *FALTA DE CONOCIMIENTOS/RECONOCIMIENTO• *HEURISTICOS Y/O CRITERIOS ERRÓNEOS• *RAZONAMIENTO• Desenfocado: Inadecuado para la situación.• Intolera “no saber”: Precipita cierre entrevista.• Pereza de reacción: Inercia diagnóstica.• Baja productividad ideativa• Confirmatorio:• Dependencia de otros.• Banaliza los síntomas/signos del paciente.•
  34. 34. DISPOSICIONES COGNITIVAS (i)(Croskerry P, The Importance of Cognitive Errors in Diagnosis and Strategies to Minimize Them , Academic Medicine 2003; 78(8): 775-780) • Aggregate bias: when physicians believe that aggregated data, such as those used to develop clinical practice guidelines, do not apply to individual patients (especially their own), they are invoking the aggregate fallacy. The belief that their patients are atypical or somehow exceptional may lead to errors of commission, e.g., ordering x-rays or other tests when guidelines indicate none are required. • Anchoring: the tendency to perceptually lock onto salient features in the patient’s initial presentation too early in the diagnostic process, and failing to adjust this initial impression in the light of later information. This CDR may be severely compounded by the confirmation bias. Ascertainment bias: occurs when a physician’s thinking is shaped by prior expectation; stereotyping and gender bias are both good examples. • Availability: the disposition to judge things as being more likely, or frequently occurring, if they readily come to mind. Thus, recent experience with a disease may inflate the likelihood of its being diagnosed. Conversely, if a disease has not been seen for a long time (is less available), it may be underdiagnosed. • Base-rate neglect: the tendency to ignore the true prevalence of a disease, either inflating or reducing its base-rate, and distorting Bayesian reasoning. However, in some cases, clinicians may (consciously or otherwise) deliberately inflate the likelihood of disease, such as in the strategy of ‘‘rule out worst-case scenario’’ to avoid missing a rare but significant diagnosis. • Commission bias: results from the obligation toward beneficence, in that harm to the patient can only be prevented by active intervention. It is the tendency toward action rather than inaction. It is more likely in over-confident physicians. Commission bias is less common than omission bias. • Confirmation bias: the tendency to look for confirming evidence to support a diagnosis rather than look for disconfirming evidence to refute it, despite the latter often being more persuasive and definitive. • Diagnosis momentum: once diagnostic labels are attached to patients they tend to become stickier and stickier. Through intermediaries (patients, paramedics, nurses, physicians), what might have started as a possibility gathers increasing momentum until it becomes definite, and all other possibilities are excluded. • Feedback sanction: a form of ignorance trap and time-delay trap CDR. Making a diagnostic error may carry no immediate consequences, as considerable time may elapse before the error is discovered, if ever, or poor system feedback processes prevent important information on decisions getting back to the decision maker. The particular CDR that failed the patient persists because of these temporal and systemic sanctions. • Framing effect: how diagnosticians see things may be strongly influenced by the way in which the problem is framed, e.g., physicians’ perceptions of risk to the patient may be strongly influenced by whether the outcome is expressed in terms of the possibility that the patient might die or might live. In terms of diagnosis, physicians should be aware of how patients, nurses, and other physicians frame potential outcomes and contingencies of the clinical problem to them.
  35. 35. DISPOSICIONESCOGNITIVAS (ii) DISPOSICIONES COGNITIVAS (ii)(Croskerry P, The Importance of Cognitive Errors in Diagnosis and Strategies to Minimize Them , Academic Medicine 2003; 78(8): 775-780) • Fundamental attribution error: the tendency to be judgmental and blame patients for their illnesses (dispositional causes) rather than examine the circumstances (situational factors) that might have been responsible. In particular, psychiatric patients, minorities, and other marginalized groups tend to suffer from this CDR. Cultural differences exist in terms of the respective weights attributed to dispositional and situational causes. • Gambler’s fallacy: attributed to gamblers, this fallacy is the belief that if a coin is tossed ten times and is heads each time, the 11th toss has a greater chance of being tails (even though a fair coin has no memory). An example would be a physician who sees a series of patients with chest pain in clinic or the emergency department, diagnoses all of them with an acute coronary syndrome, and assumes the sequence will not continue. Thus, the pretest probability that a patient will have a particular diagnosis might be influenced by preceding but independent events. • Gender bias: the tendency to believe that gender is a determining factor in the probability of diagnosis of a particular disease when no such pathophysiological basis exists. Generally, it results in an overdiagnosis of the favored gender and underdiagnosis of the neglected gender. • Hindsight bias: knowing the outcome may profoundly influence the perception of past events and prevent a realistic appraisal of what actually occurred. In the context of diagnostic error, it may compromise learning through either an underestimation (illusion of failure) or overestimation (illusion of control) of the decision maker’s abilities. • Multiple alternatives bias: a multiplicity of options on a differential diagnosis may lead to significant conflict and uncertainty. The process may be simplified by reverting to a smaller subset with which the physician is familiar but may result in inadequate consideration of other possibilities. One such strategy is the three-diagnosis differential: ‘‘It is probably A, but it might be B, or I don’t know (C).’’ Although this approach has some heuristic value, if the disease falls in the C category and is not pursued adequately, it will minimize the chances that some serious diagnoses can be made. • Omission bias: the tendency toward inaction and rooted in the principle of nonmaleficence. In hindsight, events that have occurred through the natural progression of a disease are more acceptable than those that may be attributed directly to the action of the physician. The bias may be sustained by the reinforcement often associated with not doing anything, but it may prove disastrous. Omission biases typically outnumber commission biases. • Order effects: information transfer is a U-function: we tend to remember the beginning part (primacy effect) or the end (recency effect). Primacy effect may be augmented by anchoring. In transitions of care, in which information transferred from patients, nurses, or other physicians is being evaluated, care should be taken to give due consideration to all information, regardless of the order in which it was presented. • Outcome bias: the tendency to opt for diagnostic decisions that will lead to good outcomes, rather than those associated with bad outcomes, thereby avoiding chagrin associated with the latter. It is a form of value bias in that physicians may express a stronger likelihood in their decision-making for what they hope will happen rather than for what they really believe might happen. This may result in serious
  36. 36. DISPOSICIONES COGNITIVAS (iii) DISPOSICIONES COGNITIVAS(iii)(Croskerry P, The Importance of Cognitive Errors in Diagnosis and Strategies to Minimize Them , Academic Medicine 2003; 78(8): 775-780) • Overconfidence bias: a universal tendency to believe we know more than we do. Overconfidence reflects a tendency to act on incomplete information, intuitions, or hunches. Too much faith is placed in opinion instead of carefully gathered evidence. The bias may be augmented by both anchoring and availability, and catastrophic outcomes may result when there is a prevailing commission bias. • Playing the odds: (also known as frequency gambling) is the tendency in equivocal or ambiguous presentations to opt for a benign diagnosis on the basis that it is significantly more likely than a serious one. It may be compounded by the fact that the signs and symptoms of many common and benign diseases are mimicked by more serious and rare ones. The strategy may be unwitting or deliberate and is diametrically opposed to the rule out worst-case scenario strategy (see base-rate neglect). • Posterior probability error : occurs when a physician’s estimate for the likelihood of disease is unduly influenced by what has gone on before for a particular patient. It is the opposite of the gambler’s fallacy in that the physician is gambling on the sequence continuing, e.g., if a patient presents to the office five times with a headache that is correctly diagnosed as migraine on each visit, it is the tendency to diagnose migraine on the sixth visit.Common things for most patients continue to be common, and the potential for a nonbenign headache being diagnosed is lowered through posterior probability. • Premature closure: a powerful CDR accounting for a high proportion of missed diagnoses. It is the tendency to apply premature closure to the decisionmaking process, accepting a diagnosis before it has been fully verified. The consequences of the bias are reflected in the maxim: ‘‘When the diagnosis is made, the thinking stops.’’ • Psych-out error : psychiatric patients appear to be particularly vulnerable to the CDRs described in this list and to other errors in their management, some of which may exacerbate their condition. They appear especially vulnerable to fundamental attribution error. In particular, comorbid medical conditions may be overlooked or minimized. A variant of psych-out error occurs when serious medical conditions (e.g., hypoxia, delerium, metabolic abnormalities, CNS infections, head injury) are misdiagnosed as psychiatric conditions. • Representativeness restraint: the representativeness heuristic drives the diagnostician toward looking for prototypical manifestations of disease: ‘‘If it looks like a duck, walks like a duck, quacks like a duck, then it is a duck.’’ Yet restraining decision-making along these pattern- recognition lines leads to atypical variants being missed. • Search satisfying : reflects the universal tendency to call off a search once something is found. Comorbidities, second foreign bodies, other fractures, and coingestants in poisoning may all be missed. Also, if the search yields nothing, diagnosticians should satisfy themselves that they have been looking in the right place.
  37. 37. DISPOSICIONES COGNITIVAS (iv) DISPOSICIONES COGNITIVAS(iv)(Croskerry P, The Importance of Cognitive Errors in Diagnosis and Strategies to Minimize Them , Academic Medicine 2003; 78(8): 775-780) • Sutton’s slip: takes its name from the apocryphal story of the Brooklyn bank-robber Willie Sutton who, when asked by the Judge why he robbed banks, is alleged to have replied: ‘‘Because that’s where the money is!’’ The diagnostic strategy of going for the obvious is referred to as Sutton’s law. The slip occurs when possibilities other than the obvious are not given sufficient consideration. • Sunk costs: the more clinicians invest in a particular diagnosis, the less likely they may be to release it and consider alternatives. This is an entrapment form of CDR more associated with investment and financial considerations. However, for the diagnostician, the investment is time and mental energy and, for some, ego may be a precious investment. Confirmation bias may be a manifestation of such an unwillingness to let go of a failing diagnosis. • Triage cueing : the triage process occurs throughout the health care system, from the self-triage of patients to the selection of a specialist by the referring physician. In the emergency department, triage is a formal process that results in patients being sent in particular directions, which cues their subsequent management. Many CDRs are initiated at triage, leading to the maxim: ‘‘Geography is destiny.’’ • Unpacking principle : failure to elicit all relevant information (unpacking) in establishing a differential diagnosis may result in significant possibilities being missed. The more specific a description of an illness that is received, the more likely the event is judged to exist. If patients are allowed to limit their history-giving, or physicians otherwise limit their history-taking, unspecified possibilities may be discounted. • Vertical line failure: routine, repetitive tasks often lead to thinking in silos—predictable, orthodox styles that emphasize economy, efficacy, and utility. Though often rewarded, the approach carries the inherent penalty of inflexibility. In contrast, lateral thinking styles create opportunities for diagnosing the unexpected, rare, or esoteric. An effective lateral thinking strategy is simply to pose the question: ‘‘What else might this be?’’ • Visceral bias : the influence of affective sources of error on decision-making has been widely underestimated. Visceral arousal leads to poor decisions. • Countertransference, both negative and positive feelings toward patients, may result in diagnoses being missed. Some attribution phenomena (fundamental attribution error) may have their origin in countertransference. • Yin-Yang out : when patients have been subjected to exhaustive and unavailing diagnostic investigations, they are said to have been worked up the Yin-Yang. The Yin-Yang out is the tendency to believe that nothing further can be done to throw light on the dark place where, and if, any definitive diagnosis resides for the patient, i.e., the physician is let out of further diagnostic effort. This may prove ultimately to be true, but to adopt the strategy at the outset is fraught with the chance of a variety of errors.
  38. 38. ESTRATEGIAS DE MEJORA• EL PROFESIONAL• EL SISTEMA
  39. 39. ESTRATEGIAS DE MEJORA: EL PROFESIONAL.• FORMAR – Patrones de reconocimiento de trastornos/ enfermedades y sus complicaciones. – Script de los trastornos/enfermedades. – Situaciones de alarma.• COMPARTIR – Experiencias clínicas. – Asesoramiento/tutorización directa.• DAR FEEDBACK
  40. 40. Propósito Asunción Insuficiencias EnfoqueFORMACIONMetacognición Hábitos Conductas Caro Individuo mas complejasExperteza Conocimientos Reconocer Caro IndividuoCOMPARTIREn línea Validar Amplia opciones No inmediato Individuo Sugerir otros Diagn.Segunda opinión Idem Compartir criterios Solo casos Equipo “especiales”Sistema experto Sugerir Exhaustividad Solo casos Individuo “especiales”ParticipaciónpacienteFEEDBACKAutopsias Mejorar experiencia clínica Relacionar síntomas y Caro, solo casos Equipo signos con diag no “especiales”, obvios resistencia familiaresAudit Mejorar procedimientos Disciplina trabajo Nexo no bien Individuo / conlleva mejores establecido Equipo resultadosSeguimiento Rectificar Ganar en flexibilidad; Exige planificar. Individuo / Evitar error o Equipo disminuir efectos.
  41. 41. ESTRATEGIAS DE MEJORA: EL SISTEMA.• MEJORAR EL RESCATE DE INFORMACION.• MEJORAR LA COMUNICACIÓN ENTRE PROFESIONALES Y EL ACCESO A PRUEBAS.• SISTEMAS EXPERTOS• ALERTAS• TAREAS PENDIENTES• GESTION DE POBLACIONES A RIESGO
  42. 42. HISTORIA CLÍNICA ELECTRÓNICA• TAPIZ – LISTA PROBLEMAS – CURSO CLÍNICO • PROBLEMAS/EPISODIOS – PRESCRIPCIONES – HOJA MONITORIZACIÓN, HISTORICO DE PRUEBAS…• INTERCONECTIVIDAD – PRUEBAS COMPLEMENTARIAS – HISTORIA CLINICA ELECTRONICA – CURSOS CLÍNICOS OTROS PROFESIONALES.
  43. 43. ALERTAS • ANALITICAS /RADIOLOGIAEN EL MOMENTODE LA CONEXION • ALTAS HOSPITALARIAS/URGENCIAS • INTERCONSULTAS ESPECIALISTAS • DEFUNCIONESDURANTE EL ACTO • PREASEGCLÍNICO • TAREAS PENDIENTES
  44. 44. PERFIL PRESCRIPCION • ON TIME (PREFASEG): – INTERACCIONES. – REDUNDANCIAS (DUPLICADOS) – EDADES EXTREMAS – ENFERMEDADES/CONDICIONES DEL PACIENTE – REACCIONES ADVERSAS /ALERGIAS – TUTOR PEDIATRIA • OFF TIME (SELF AUDIT): – REDUNDANCIAS (DUPLICADOS). – MAS DE 10 FÀRMACOS – NO RECOMENDADOS POR EDAD/ PROTECCIÓN GÀSTRICA, ETC.
  45. 45. GESTION DEPOBLACIONES A RIESGO • OFF TIME – EPOC. – DIABETICOS – RIESGO CARDIOVASCULAR – OTROS… • EN UN FUTURO – POBLACION DE ESPECIAL SEGUIMIENTO: • DEFINIDO POR VARIOS FACTORES • DEFINIDO POR EL PROFESIONAL – POBLACION DETECTADA POR SISTEMAS EXPERTOS. • VARIABLES BIOLOGICAS • VARIABLES PSICOSOCIALES
  46. 46. Prescripción Farmacológica Segura PREFASEG Autores: CAMFiC i ICS Ester Amado Arantxa Catalán Leonardo Galván Jose Miguel Baena Vicente Morales Gladys Bendahan Míriam Oms Francesc Borrell Àngels Pons Con la colaboración de: Fundació Avedis Donabedian Subdirecció General de Recursos SanitarisFinanciación: Aliança per la Seguretat dels Pacients (Departament de Salut, 2007) Ministerio de Sanidad y Política Social (Seguridad de pacientes, 2009)
  47. 47. PARA SABER MAS• Aranaz JM, Aibar C, Vitaller J, Mira JJ Gestión Sanitaria. Calidad y Seguridad de los pacientes. Fundación MAPFRE. Diaz de Santos, Madrid 2008.• Baron J. Thinking and Deciding. 3rd ed. Cambridge, UK:• Cambridge University Press; 2003.• Gigerenzer G. Simple Heuristics that Make Us Smart. Oxford, UK: Oxford University Press; 1999.• Kassirer JP, Kopelman RI. Learning Clinical Reasoning.• Baltimore, MD: Williams & Wilkins; 1991.• Godoy A. Toma de decisiones y juicio clínico. Piramide. Madrid 1996.• Dowie JU, Elstein A. Professional judgement. A reader in clinical decision making. Cambridge University Press. New York 1988
  48. 48. PARA SABER MAS• Society of Medical Decision Making (available at: http://www.smdm.org•• The Brunswik Society (available at: http://www.brunswik.org )• Decision Analysis Society (available at: http://faculty.fuqua.duke.edu/daweb )• Society for Judgment and Decision Making (available at: http://www.sjdm.org)• Center for Adaptive Behavior and Cognition (available at:• http://www.mpib-berlin.mpg.de/en/research/adaptive-behavior-and-cognition• AHRQ Web M&M, October 2007. Available at: http://www.webmm.ahrq.gov/index.aspx
  49. 49. MUCHAS GRACIAS POR VUESTRA ATENCION NOS VEMOS EN: www.humedicas.blogspot.com www.seguridadclinica.blogspot.com

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