Human Factors
James (Jeb) Buchanan, M.D.
Fort Wayne Med Ed Program
Case Presentation
• 16 y/o G1P0 term
• Nurse 12 hr shift asked to stay another
4 hours
• + GBBS
• Pt requests epidural
• AN known to be passive aggressive
• Needs PCN for GBBS
Administrative Legislation
Because I said so!!
Herding Cats
Herding (constraining) vs. attracting (value)
Exhortation
• Knowledge of the right thing to do isn’t
enough to effect change.
• Safety occurs not from exhortation but
by system (science) changes.
• Exhortation of trying harder, remember
better next time does not work.
– Cognitive fatigue
All Washed Up
• Video
• Influencer
– Patterson/Grenny
• All Washed Up!
• http://www.youtube.com/watch?v=osUw
ukXSd0k
VisCog Demonstrations
Three Demos
Situational Awareness
Gradated
Door
Required VisCog copyright notification
Demonstration of Cognitive
Blindness
What is changing?
– Average 20-40
alternations to detect
– http://www.cs.ubc.ca/
~rensink/flicker/down
load/Airplane.mov
Human Factors
Inattentive Blindness/Cognitive Blindness
– The phenomenon of not being able to
perceive things that are in plain sight
(Simmons, D; Rensink, R;Rock, I; Neisser, U)
The Cognitive Underpinning
• Results from no internal frame of
reference to perceive the unseen
objects
• Mental focus or attention which cause
mental distractions – loss of situational
awareness
• Cause of misdiagnosis
Pattern Matchers
Look-a-Likes
Pattern Matching
Sound-a-likes
Look-alike – Sound-alike
Problematic Combinations
•
•
•
•
•
Actos – Actonel
Avinza – Evista
Cardene – Cardizem
Cardura – Coumadin
Celebrex – Celexa –
Cerebyx
• Clonidine – Clonazepam
(Klonopin)
• Depakote – Depakote ER
• Epinephrine – Ephedrine
•
•
•
•
•
Florastor – Floranex
Hydroxyzine – Hydralazine
Lamivudine – Lamotrigine
Remeron – Rozerem
Risperdal (risperidone) –
Requip (ropinirole)
• Wellbutrin - Wellbutrin SR
– Wellbutrin XL
• Zyprexa – Zyrtec
•
Tara Jellison, PharmD
Pattern Matching
• Eliminate look-a-likes/sound-a-likes
• TJC /ISMP prohibited abbreviation
– Physicians more likely to adhere to these
prohibited abbreviations once they are
educated on pattern matching….rather
than exhortation by authority figure.
• Illegibility
Medical Errors
• Limited abilities to
multitask (~7 tasks)
• Nurses at times 1726
Multitasking
vs.
Rapid Cycling
• Mary had a little lamb
• Home phone number
Medical Errors
• Under stress (type felt in your chest)
errors increase to 25%
• Nurses > 12 hrs – 3X error rate
• Physicians 24 hrs no sleep = 0.1%
EtOH
• Fatigue – 3X needlestick injuries in
residents
• Teamwork – decrease error rate 5X
Alarm Fatigue
• TJC Sentinel Event Alert Issue 50, April
8, 2013
• Bedside telemetry, pulse ox, BP
monitors, infusions pumps, vents,
central monitors, etc.
• Per patient – can reach several
hundred/day
• Per unit – 1000s/day; Per Hospital –
tens of thousands/day
Alarm Fatigue
• 85-99% of alarms do not require clinical
intervention.
• Failure modes which lead to alarm
fatigue:
– Alarms with similar sounds
– Default settings not changed to individual
patient
– Alarm conditions set too tight
– Sensors are mispositioned
– Electrodes dried out
Alarm Fatigue
• Human response to number of alarms:
– Turn down the volume
– Turn off the alarm
– Adjust settings outside of safe limits for that
particular patient
• End result in some – serious
complications or death
Diagnostic Failure
Diagnostic Failure
is Not:
• Nostalgialitis Imperfecta – we were just
as bad in diagnostic error in the 1970s.
• Idiopathic
– Idiot…..the doctor
– Pathetic……for the patient
Diagnostic Failure
Harm caused by:
Wrong Diagnosis
Delayed Diagnosis
Missed Diagnosis
Diagnostic Failure
(Missed, Delayed, Wrong)
• Result in 40,000 to 80,000 U.S. hospital
deaths annually.
• 5-14% of hospital admissions involve a
missed diagnosis
• Diagnostic errors ~10% of these
mistakes result in death.
Diagnostic errors: Why They Happen; amednews; Dec.
6, 2010.
Incidence
• US primary care outpatient visits
– 50,000/yr most leading to “considerable
harm”
• Adding estimate for outpatient specialty
visits and nonlethal hospital diagnostic
errors
– 150,000 US patients have misdiagnosis
harm.
JAMA Internal Med, Newman-Toker, Makary, Feb,
2013
BMJ Quality and Safety
April 2013
• Look back of 350,000 medmal claims
over 25 years (via NPDB)
• 160,000 patients/yr – death or
permanent injury. Probably much
higher since estimate based on
claims…and most errors don’t lead to
claims.
• Diagnostic Failure 29% of claims
BMJ Article
• Outpatient > Inpatient
– 68.8% vs. 31.2%
• Inpatient more lethal
• 48.4% vs. 36.9%
– Majority are missed diagnosis – 54%, then
delay in Dx – 19.9%, then wrong Dx – 9.9%
– Resulted in 2x M&M compared to other error
categories.
Diagnostic Failure
Punch Lines
• #1 cause of malpractice in US and
Canada 2011
– 40% of liability suits
• Increase hospital costs by 80%
• Underappreciated and under
recognized
• Not being publically reported/tracked
– Who wants to tell public 10-20% diagnosis
missed. (BMJ)
Wall Street
Journal
April 23, 2013
Public Interest
WSJ Nov 18,2013
Best
Doctors
August 2013
Diagnostic Failure
• Most research articles are since 2000.
• 2007, AHRQ identified diagnostic error
as an area of special emphasis
• 2008, WHO Alliance for Patient Safety
identified diagnostic error as a research
priority
• 2008, the first international conference
on Diagnostic Error in Medicine
• 2011, Society to Improve Diagnosis in
Medicine (SIDM)
Diagnostic Failure
• Diagnostic error is the next frontier in
patient safety.
• “There is hardly an extended circle of
family and friends that has not been
touched by diagnostic error.”
Society to Improve Diagnosis in Medicine (SIDM) 2011
Have you or your family had a
wrong diagnosis or delayed
diagnosis which led to harm?
1. Yes
2. No
Response
Counter
0%
1.
0%
2.
15
Have you been sufficiently trained on:
Cognitive and Affective Biases
Heuristics
Advanced critical thinking specifically on:
Decision-making
Cognitive debiasing?
1. Yes
2. No
0%
Response
Counter
1.
0%
2.
10
Are you presently training residents on:
Cognitive and affective biases
Heuristics
Advanced Critical thinking specifically on:
Decision-making
Cognitive debiasing?
1. Yes
2. No
0%
Response
Counter
1.
0%
2.
10
Diagnostic Failure
Physicians receive little or no training on
decision-making or on the influence of
cognitive and affective biases. They do
not generally reflect upon or view
introspectively their own decision-making
behaviors.
Diagnostic Failure
• Diagnostic failure is the highest where
uncertainty and ambiguity are high
– Emergency medicine
– Family practice
– Internal medicine
(Brennan et al. 1991; Thomas et al. 2000; Wilson et al. 1995).
– 15% overall broad-based failure rate
Berner and Graber (2008)
Diagnostic Failure
• In the perceptual specialties which rely
on visual interpretation
– Pathology
– Dermatology
– Radiology
– 2–5%
Berner and Graber (2008)
Diagnostic Failure
Experienced physicians make most of
their diagnostic decision-making quickly
and effectively in the intuitive mode using
pattern recognition. However, they switch
to analytical mode for novel,
ambiguous/undifferentiated and more
challenging cases. (Lakoff and Johnson
1999)
Intuitive Mode
Higher level pattern patching
– Car
– Reading
– Driving
– Diagnosing
System 1 Intuitive
•
•
•
•
Rapid
Unconscious
Intuitive
Primarily pattern matching
System 2 Analytic
•
•
•
•
•
•
Slow
Conscious
Effortful
Logical
Systematic
Based on explicit rules such as those
governing clinical diagnosis
Intuitive vs Analytic
• fMRI – anatomical localization
• Glucose availability – see switch from
intuitive to analytic can be seen
• Neurologic damage – individuals with
such can lose capacity
Intuitive Thinking
Medial Prefrontal Cortex (mPFC)
Executive Function
Experts
Interns
Impact of Sleep & Burnout
(Emotional Exhaustion &
Depersonalization)
• Fatigue/lack of sleep acted same as cognitive
overload and deactivated mPFC for both experts and
interns.
• Burnout impacted interns on fMRI but not experts
Diagnostic Failure
• Heuristics (thinking shortcuts/rules of
thumbs) predominate in the intuitive
mode. (Gilovich et al. 2002).
• Errors typically have their origins in
failed heuristics and the maladaptive
influence of cognitive and affective
biases.
• Heuristics/cognitive biases - their power
should not be underestimated.
Diagnostic Failure
• Cognitive factors are implicated in about
75% of diagnostic errors; Graber et al.
(2005)
• Large population-based Dutch study
(8,000), cognitive factors were
estimated at 96% (Zwaan et al. 2010).
Diagnostic Failure
• One in three diagnostic errors results
solely from physicians' cognitive
mistakes.
• The rest are caused by system factors
or a combination of cognitive and
system errors.
Archives of Internal Medicine; July 11, 2005
Diagnostic Failure
• The majority of diagnostic errors are
associated with common conditions
such as pulmonary embolism, sepsis,
myocardial infarction and appendicitis
(Zwaan et al. 2010).
• Often atypical presentations
• Pulmonary embolism is #1
• 80% of time no differential diagnoses on
the chart.
Top Diagnostic Failures in
Outpatient
•
•
•
•
•
Pneumonia
Worsening CHF
Acute renal failure
Cancer
Urinary tract infection
Types and Origins of Diagnostic Errors in Primary Care Settings; Singh. H,
M.D. et. Al; JAMA Internal Medicine. 2013;173(6):418-425
Diagnostic Failure
• It is not common (4%) for the diagnostic
failure to be secondary lack of knowledge of
the disease.
• How physicians think and not what physicians
know (4%) is primarily responsible for
diagnostic failure.
• An important distinction because it directs
where remedial action should be taken to
improve reasoning and patient safety.
Diagnostic Failure
• An accurate diagnosis is more likely in
the analytical mode (which is more
cognitive fatiguing)
• In order to get to it, the physician must
decouple from the intuitive mode
through the processes of cognitive
debiasing and cognitive forcing
strategies.
Diagnostic Failure
Not all cognitive biases are created equal
and different cognitive pills might be
needed for the different ills. (Keren 1990,
Larrick 2004).
“Cognitive Pills for Cognitive Ills”
Cognitive Pills for Cognitive Ills
• Successful debiasing requires repeated
training using a variety of strategies
(Croskerry and Nimmo 2011; Hogarth 2001).
• Draws heavy physician interest
• Page 8 on Case Review Sheet (Handout #2)
Diagnostic Error
80% of Diagnostic Failure:
Documentation lacked a Differential
Diagnosis.
Commitment to Change
Statement
Master Diagnostician
Handout
JAMA
August 14, 2013
Diagnostic Failure
Good Reviews
– References listed at end of PowerPoint
slides
References - Diagnostic Failure
•
•
•
•
•
•
•
"Addressing Diagnostic Errors: An Institutional Approach," Focus on Patient
Safety, Fall (www.npsf.org/paf/npsfp/fo/pdf/focus v13-3-2010.pdf)
"Why diagnostic errors don't get any respect -- and what can be done about
them," Health Affairs, September
(content.healthaffairs.org/cgi/content/abstract/29/9/1605)
"Thinking about diagnostic thinking: a 30-year perspective," Advances in Health
Sciences Education: Theory and Practice, September 2009
(www.ncbi.nlm.nih.gov/pubmed/19669916)
"Diagnostic Errors -- The Next Frontier for Patient Safety," The Journal of the
American Medical Association, March 11, 2009 (jama.amaassn.org/cgi/content/short/301/10/1060)
"Diagnostic Error in Internal Medicine," Archives of Internal Medicine, July 11,
2005 (archinte.ama-assn.org/cgi/content/abstract/165/13/1493)
"The importance of cognitive errors in diagnosis and strategies to minimize
them," Academic Medicine, August 2003
(www.ncbi.nlm.nih.gov/pubmed/12915363)
"Diagnostic Error in Medicine" annual meetings, Society for Medical Decision
Making (www.smdm.org/diagnostic_errors.shtml)
References - Diagnostic Failure
• Scott, I. Errors in Clinical Reasoning: Causes
and Remedial Strategies, BMJ, V339, 2009
• Bordage, G. Why Did I Miss the Diagnosis?
Some Cognitive Explanations and Educational
Implications, Acad. Med. 74(s)m 1999
• http://psnet.ahrq.gov/primer.aspx?primerID=12
(diagnostic errors)
• Society for Medical Decision Making
References - Diagnostic Failure
• Overconfidence in Clinical Decision Making;
Croskerry; American J. of Medicine (2008)
Vol 121 (5A), S24-S29.
• Diagnostic Errors: Why They Happen;
O’Reilly; AMANews; Dec. 6, 2010
• Diagnostic Failure: A Cognitive and Affective
Approach; Croskerry; Advances in Patient
Safety, Vol.2.
• Perspectives on Diagnostic Failure and
Patient Safety; Croskerry; Healthcare
Quarterly, 15 (Special Issue) 2012: 50-56.
References - Diagnostic Failure
• Patient Safety Strategies Targeted at
Diagnostic Errors – A Systemic Review;
McDonald, K., et. al.; Annals of Internal
Medicine; March 5, 2013; Vol. 158 N0. 5
Page 381-389.
• JAMA Internal Med, Newman-Toker, Makary,
Feb, 2013
References - Diagnostic Failure
25-Year summary of U.S. malpractice
claims for diagnostic errors 1986-2010: an
analysis from the National Practitioner
Data Bank, BMJ Quality & Safety,
published online April 22, 2013
References – Diagnostic Failure
• Seen Through Their Eyes: Residents’ Reflections on
the Cognitive and Contextual Components of
Diagnostic Errors in Medicine; Alexis R., et al.,
Academic Medicine. 2012; 87:1361-1367
• James, J A; New Evidence-based Estimate of Patient
Harms Associated with Hospital Care; Journal of
Patient Safety; Sept 2013;Vol 9 –Issue 3: 122-128.
References – Diagnostic Failure
• Using Functional MRI to Improve How We
Understand, Teach, and Assess Clinical Reasoning;
Durning S., et al., J. of Continuing Education in the
Health Professions, 34(1):76-82, 2014.
• Why Do Doctors Make Mistakes? A Study of the Role
of Salient Distracting Clinical Features; Mamede S.,
et al., Acad Med. 2014; 89:114-120
• Exposure to Media Information About a Disease Can
Cause Doctors to Misdiagnose Similar-Looking
Clinical Cases; Schmidt H; Acad Med. 2014; 89:285291.
References – Diagnostic Failure
• Deciding About Fast and Slow Decisions; Croskerry
P et al.; Acad Med. 2014; 89: 197-200.
• The Etiology of Diagnostic Errors: A Controlled Trial
of System 1 Versus System 2 Reasoning; Norman G,
et al.; Acad Med. 2014; 89: 277-284