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A Preventable Mode of Diagnostic Journal of Evaluation in Clinical Practice ISSN 1356-1294 Misleading one detail: a preventable mode of diagnostic error?jep_1098 804..806 Shahar Arzy MD PhD,1 Mayer Brezis MD MPH,2 Salim Khoury MD,3 Steven R. Simon MD MPH4 and Tamir Ben-Hur MD PhD5 1Neurologist, Department of Neurology, Hadassah Hebrew University Hospital, Jerusalem, Israel and Research fellow, Laboratory of Cognitive Neuroscience, Brain Mind Institute, Ecole Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland 2Professor, Centre for Clinical Quality and Safety, Hadassah Hebrew University Hospital, Jerusalem, Israel 3Neurologist, Department of Neurology, Hadassah Hebrew University Hospital, Jerusalem, Israel 4Associate Professor, Department of Ambulatory Care and Prevention, Harvard Medical School and Harvard Pilgrim Health Care, Boston, MA, USA 5Head and Professor of Neurology, Department of Neurology, Hadassah Hebrew University Hospital, Jerusalem, Israel Keywords Abstract clinical decision making, clinical errors, cognitive disposition Rationale, aims and objectives Despite advances in our understanding of cognitive biases in clinical practice, little is known about correction or prevention of diagnostic errors. The Correspondence presence of a single misleading detail may lead clinicians down a cognitive and actual path Dr Shahar Arzy toward an incorrect diagnosis. Department of Neurology Methods In a large teaching hospital, we surveyed 51 attending doctors in internal medi- Hadassah Hebrew University Hospital cine, presenting each with 10 clinical vignettes and soliciting their diagnosis of the con- 91120 Jerusalem dition leading to the presentation. Each of the 10 clinical cases included a single misleading Israel detail. E-mail: [email protected] Results This survey elicited a wrong diagnosis in 90% of cases, which was reduced to 30% when omitting the misleading detail from the vignette. Diagnostic accuracy did not Accepted for publication: 15 July 2008 improve by warning doctors about potentially misleading information. Asking doctors to identify a leading diagnostic detail and then to formulate an alternative diagnosis after doi:10.1111/j.1365-2753.2008.01098.x omission of the detail, significantly reduced diagnostic error rate by nearly 50%. Conclusion Systematic re-examination of leading diagnostic clues may help to reduce errors in diagnosis. Introduction to reduce the number of false MODEs that result in erroneous medical decisions. However, the presence of true MODEs that Errors in diagnosis occur frequently, delaying identification of the divert clinical thinking may be very common. Recognition of both correct diagnosis and resulting in adverse clinical events. Incorrect types of errors might allow reduction of mistakes in clinical deci- or delayed diagnoses are the most common reason for medical sion making. We therefore undertook the present study to investi- malpractice claims in the USA [1]. Despite advances in our under- gate the relationship between MODEs and clinical diagnostic standing of cognitive biases in clinical practice [2–4], little is errors among practicing doctors. known about how overcoming those biases may prevent or correct errors in diagnosis. In clinical thinking, one prominent detail Methods might modify an otherwise simple clinical picture. This mislead- ing one detail (MODE) might originate from false information Fifty-one attending doctors in internal medicine at a university (false MODE: incorrect history or physical examination, misinter- hospital were recruited to participate in this study. Participants pretation or misreporting of imaging or laboratory results), or real were informed that the purpose of the study was to evaluate the findings that are nevertheless not related to the present problem knowledge of internists at the hospital. The 51 participants were (true MODE: e.g. social or demographic characteristics, prior con- randomly allocated to three separate groups: one group received dition or current co-morbidity, or accurate but irrelevant finding on the clinical case with an embedded MODE but received no special physical examination, laboratory investigation or diagnostic notification or instruction to be aware of MODEs (MODE group, imaging). A major goal of clinical quality and safety in medicine is n = 17). A second group received the same clinical cases but was 804 © 2009 The Authors. Journal compilation © 2009 Blackwell Publishing Ltd, Journal of Evaluation in Clinical Practice 15 (2009) 804–806 S. Arzy et al. Preventable mode of diagnostic error instructed to be aware of possible misleading details in case (MODE-notified group, n = 17). A third group received the same case but with a trivial detail substituted for the MODE (non- MODE group, n = 17). Each doctor was asked to read 10 clinical case presentations, composed from five different details each. Cases were based on real cases witnessed in the emergency room, in which a misleading detail caused misdiagnosis (Box 1). For each case, participants were first asked to indicate the most prob- able diagnosis and the first management option to be taken. After completing this step, MODE group and MODE-notified group participants were instructed to indicate the most influential detail in each case. Participants were then asked to reconsider their diagnosis and management approach if the most influential detail they identified had been absent. Each correct response (see Box 1) was credited with one point, and the mean numbers of correct responses per case in each study group were then compared. Repeated-measures anovas were run on the responses with the factor MODE between the three groups. A second statistical test (repeated-measures anovas) was then run with the factors notifi- cation (with and without) and revision (before and after) between the MODE group and MODE-notified group. Then, to test possible relationships between MODE’s identification and the revised answers, correlation analysis was performed between responses for the different questions and the corrected answers. Analyses were performed for the whole sample, using Pearson product moment correlations. All P-values are two-tailed, and the signifi- cance level was set to a = 0.05. Figure 1 Analysis of doctors’ responses. (a) Percentages of correct Box 1 Examples of clinical cases. Each case was comprised from responses are plotted separately for the three different groups (MODE five different details with a misleading one detail (MODE; bolded) in group, MODE-notified group, non-MODE group) before (grey) and after the patient’s history (case a), physical examination (case b) or inves- (black) MODE identification. Note the lower results for the MODE and tigation (case c). The MODEs could be true (cases a,b) or false (case MODE-notified group than that for the non-MODE group as well as the c). The right answer is written in brackets following by the common significant improvement after MODE identification (grey vs. black bars). answer of participants. (b) Revised results for the MODE group are plotted as a function of MODE identification showing a positive correlation. MODE, misleading a. A generally healthy 21-year-old girl is referred for the fourth time one detail. to the emergency room, complaining of pain in her right lower ribs since falling down during skiing 3 months ago. Physical exami- nation reveals a hard thin painful mass above the right lateral lower group and the MODE-notified group (notification effect: aspects of ribs 5–7. Chest X-ray is within normal limits (non- F = 0.23; P = 0.64). The average number of correct diagnoses Hodgkin’s lymphoma/trauma). (1,9) significantly improved in these study groups when participants b. A 67-year-old man, university professor, who is known to suffer were instructed to disregard the most influential detail and revise from multiple vascular risk factors, is brought to the emergency < room after being found in a confused state with difficulty speaking. their decision (revision effect: F(1,9) = 16.4; P 0.01; Fig. 1a). The The nurse reports a blood pressure of 188/96 and the ECG is increase attributable to the instruction to disregard the MODE was within normal limits (hypoglycaemia/stroke). similar in both groups, as no significant interaction was found c. A 40-year-old woman is suffering from general weakness and between effects (F(1,9) = 0.004; P = 0.95). Post hoc (Scheffé) shortness of breath. Two weeks ago she was hit on her chest while analysis showed significant improvement after revision in both sitting on a ski elevator. Physical examination reveals reduced ven- MODE and MODE-notified groups (P < 0.001 for both groups). tilation over the lower left lung and chest X-ray shows left lower Notably, MODE-identification correlated positively with the lobe infiltrate (haemothorax/pneumonia). revised responses in the MODE group (r = 0.96; P < 0.001; Fig. 1b) as well as in the MODE-notified group (r = 0.91; P < 0.001). Results Discussion The average number of correct initial diagnoses in the MODE group and MODE-notified group was significantly lower than A survey of physicians in internal medicine using clinical vignettes the non-MODE group (MODE effect: F(2,18) = 81.5; P < 0.001; showed that a single misleading detail (MODE) can elicit a wrong Fig. 1a). There was no significant difference between the MODE diagnosis in 90% of cases, reducing to 30% when omitting the © 2009 The Authors. Journal compilation © 2009 Blackwell Publishing Ltd 805 Preventable mode of diagnostic error S. Arzy et al. detail from the vignette. Diagnostic accuracy did not improve by Acknowledgement
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