Prevention Of Diagnostic Errors Research Articles

Evaluation of the efficiency of the expert medical decision making system in diagnosis acute appendicitis

Evaluation of the efficiency of the expert medical decision making system in diagnosis acute appendicitis

Debiasing and Educational Interventions in Medical Diagnosis: A Systematic Review

Background: The prevalence of cognitive bias and its contribution to diagnostic errors has been documented in recent research. Debiasing interventions or educational initiatives are key in reducing the effects and prevalence of cognitive biases, contributing to the prevention of diagnostic errors. The objectives of this review were to 1) characterize common debiasing strategies implemented to reduce diagnosis-related cognitive biases, 2) report the cognitive biases targeted, and 3) determine the effectiveness of these interventions on diagnostic accuracy. Methods: Searches were conducted on April 25, 2022, in MEDLINE, EMBASE, Healthstar, and PsycInfo. Studies were included if they presented a debiasing intervention which aimed to improve diagnostic accuracy. The Rayyan review software was used for screening. Quality assessments were conducted using the JBI Critical Appraisal Tools. Extraction, quality assessment and analysis were recorded in Excel. Results: Searches resulted in 2232 studies. 17 studies were included in the final analysis. Three major debiasing interventions were identified: tool use, education of biases, and education of debiasing strategies. All intervention types reported mixed results. Common biases targeted include confirmation, availability, and search satisfying bias. Conclusion: While all three major debiasing interventions identified demonstrate some effectiveness in improving diagnostic accuracy, included studies reported mixed results when implemented. Furthermore, no studies examined decision-making in a clinical setting, and no studies reported long-term follow-up. Future research should look to identify why some interventions demonstrate low effectiveness, the conditions which enable high effectiveness, and effectiveness in environments beyond vignettes and among attending physicians. PROSPERO registration number: CRD42022331128

Design, implementation, and evaluation of the computer-aided clinical decision support system based on learning-to-rank: collaboration between physicians and machine learning in the differential diagnosis process

BackgroundWe are researching, developing, and publishing the clinical decision support system based on learning-to-rank. The main objectives are (1) To support for differential diagnoses performed by internists and general practitioners and (2) To prevent diagnostic errors made by physicians. The main features are that “A physician inputs a patient's symptoms, findings, and test results to the system, and the system outputs a ranking list of possible diseases”.MethodThe software libraries for machine learning and artificial intelligence are TensorFlow and TensorFlow Ranking. The prediction algorithm is Learning-to-Rank with the listwise approach. The ranking metric is normalized discounted cumulative gain (NDCG). The loss functions are Approximate NDCG (A-NDCG). We evaluated the machine learning performance on k-fold cross-validation. We evaluated the differential diagnosis performance with validated cases.ResultsThe machine learning performance of our system was much higher than that of the conventional system. The differential diagnosis performance of our system was much higher than that of the conventional system. We have shown that the clinical decision support system prevents physicians' diagnostic errors due to confirmation bias.ConclusionsWe have demonstrated that the clinical decision support system is useful for supporting differential diagnoses and preventing diagnostic errors. We propose that differential diagnosis by physicians and learning-to-rank by machine has a high affinity. We found that information retrieval and clinical decision support systems have much in common (Target data, learning-to-rank, etc.). We propose that Clinical Decision Support Systems have the potential to support: (1) recall of rare diseases, (2) differential diagnoses for difficult-to-diagnoses cases, and (3) prevention of diagnostic errors. Our system can potentially evolve into an explainable clinical decision support system.

Avoiding cognitive bias : example of quantified assessment of muscle strength

Optimizing treatments requires the prevention of diagnostic errors. The use of shortcuts, cognitive biases, may lead to errors of judgement that can impair clinical reasoning and distort decision-making. Objective, quantifiable and comparable assessment is a safeguard against this, and for instance force quantification is used for this purpose. We will present here the use of hand-held dynamometers with recommendations for best practice as well as simple but essential tools for interpreting the results. Indeed, the use of these easy-to-use dynamometers requires rigour to ensure the quality of measurements and data analysis by/for the clinician. The use of this equipment should be widely promoted and democratized in informed clinical practice.

Clinical case of Kavasaki syndrome

Kawasaki syndrome is rare in Europe. This relatively «young» disease was first described by Japanese pediatrician Tomisaku Kawasaki in 1967. The causes of the disease are not clear. Most scientists tend to believe that the disease is triggered by existing foci of infection of viral or bacterial origin in the body, causing inflammation and damage to blood and lymphatic vessels. Kawasaki syndrome is a non­contagious disease, but cases of recurrence have been described.Patients with a high temperature, in the range of 38—40 °C, develop polymorphic rashes: roseola, erythema, urticaria, papules that can mimic measles or scarlet fever. Children are tearful, irritable, often wake up, suffer from diarrhea, abdominal pain. The rash affects the extremities and torso. The lower and upper extremities are swollen; especially pronounced swelling is on the palms, soles and fingers. After 1,5—2 weeks there is a lamellar peeling of the fingertips and toes. The interphalangeal joints are swollen, active movements in children’s joints cause pain and crying as a result. The mucous membranes of the oral cavity are hyperemic, the tongue is deep red (crimson), cheilitis is also diagnosed. There are three phases of the disease: acute — within 2 weeks since the onset, subacute — from 2 to 4 weeks, the recovery phase — from 1 to 3 months. In most patients, the cervical lymph nodes are affected, often one node is palpated ranging in size from 1 to 1.5 cm in diameter. There are no specific laboratory tests to diagnose the syndrome.Considering the sporadic nature and complexity of the diagnosis, we present a clinical case of Kawasaki syndrome in a 3.5­year­old boy. The probable cause of the disease was a combination of chickenpox virus and COVID­19. The variety of symptoms of the syndrome led to diagnostic errors and, accordingly, influenced the tactics of treatment of the primary care physician. Clinical manifestations, complications, route of the patient, complex treatment and rehabilitation are described.In our report, we have focused the attention of pediatricians, family physicians and dermatologists on the fact that Kawasaki syndrome is not a rare disease during the pandemic, and the combination of COVID­19 with other viral and microbial infections led to a multifold increase in the likelihood of serious complications. Timely diagnosis and rational therapy are the prevention of diagnostic errors and complications.

Compensation Claims in Danish Emergency Care: Identifying Hot Spots and Blind Spots in the Quality of Care.

The Healthcare Complaints Analysis Tool (HCAT) offers a validated way of systematically extracting content from patient complaints for further analysis of complaint hot spots with harm or near misses, and blind spots with, for example, systemic problems or quality problems arising during discharge. This study analyzed a Danish national sample of compensations claims about emergency care using the HCAT. Through use of the HCAT, compensation claims about Danish emergency care from 2013 to 2017 (N = 712) were coded and then grouped to identify and highlight hot spot problem areas (harm and near misses) and blind spot problem areas (admission/discharge, systemic problems, errors of omission). Two assessors coded the compensation claims by entering data into a database. The HCAT analyses of the sample resulted in coding of 1,305 problems. Most problems concerned quality and safety issues at the examination/diagnosis stage of care (63.9%). In 91.2% of the cases, the level of harm was moderate or major. Harm hot spots most often involved diagnostic errors (189 problems). Eighty-nine problems related to errors of omission, all causing moderate or major harm. For systemic blind spots, patient harm significantly increased in cases of multiple problem types in the compensation claim (odds ratio = 1.6, 95% confidence interval = 1.3-2.0). Systematic coding and analytic approach to the HCAT can highlight potential quality problems in emergency care and point to areas for further consideration. From the perspective of future health care harm prevention, there seems to be a strong incentive for further analysis of the amount, nature, and prevention of diagnostic errors in emergency care.

Clinical Decision Support Systems for Diagnosis in Primary Care: A Scoping Review.

Diagnosis is one of the crucial tasks performed by primary care physicians; however, primary care is at high risk of diagnostic errors due to the characteristics and uncertainties associated with the field. Prevention of diagnostic errors in primary care requires urgent action, and one of the possible methods is the use of health information technology. Its modes such as clinical decision support systems (CDSS) have been demonstrated to improve the quality of care in a variety of medical settings, including hospitals and primary care centers, though its usefulness in the diagnostic domain is still unknown. We conducted a scoping review to confirm the usefulness of the CDSS in the diagnostic domain in primary care and to identify areas that need to be explored. Search terms were chosen to cover the three dimensions of interest: decision support systems, diagnosis, and primary care. A total of 26 studies were included in the review. As a result, we found that the CDSS and reminder tools have significant effects on screening for common chronic diseases; however, the CDSS has not yet been fully validated for the diagnosis of acute and uncommon chronic diseases. Moreover, there were few studies involving non-physicians.

A CASE OF PROGRESSIVE DEMENTIA ON THE BACKGROUND OF LATE NEUROSYPHILIS

The objective. Prevention of diagnostic errors associated with the rare detection of syphilis in patients in neurological hospitals. Results. A clinical case from the practice of dermatovenereologists is given. Conclusions. For timely detection of neurosyphilis it is necessary to conduct a cerebrospinal fluid examination of all patients in the neurological hospital who have a positive result of non-treponemal and treponemal tests in the serum.

Teaching Critical Thinking: A Case for Instruction in Cognitive Biases to Reduce Diagnostic Errors and Improve Patient Safety

Diagnostic errors contribute to as many as 70% of medical errors. Prevention of diagnostic errors is more complex than building safety checks into health care systems; it requires an understanding of critical thinking, of clinical reasoning, and of the cognitive processes through which diagnoses are made. When a diagnostic error is recognized, it is imperative to identify where and how the mistake in clinical reasoning occurred. Cognitive biases may contribute to errors in clinical reasoning. By understanding how physicians make clinical decisions, and examining how errors due to cognitive biases occur, cognitive bias awareness training and debiasing strategies may be developed to decrease diagnostic errors and patient harm. Studies of the impact of teaching critical thinking skills have mixed results but are limited by methodological problems.This Perspective explores the role of clinical reasoning and cognitive bias in diagnostic error, as well as the effect of instruction in metacognitive skills on improvement of diagnostic accuracy for both learners and practitioners. Recent literature questioning whether teaching critical thinking skills increases diagnostic accuracy is critically examined, as are studies suggesting that metacognitive practices result in better patient care and outcomes. Instruction in metacognition, reflective practice, and cognitive bias awareness may help learners move toward adaptive expertise and help clinicians improve diagnostic accuracy. The authors argue that explicit instruction in metacognition in medical education, including awareness of cognitive biases, has the potential to reduce diagnostic errors and thus improve patient safety.

Rare Branching Pattern of the Subscapular Artery

AbstractVariations of the axillary artery and its branches are quite common. Some variations are clinically significant and having knowledge of them can be useful for the prevention of diagnostic errors during surgical interventions in the axillary fossa. Classically, the third part of the axillary artery presents three branches—the subscapular, the anterior, and the posterior circumflex humeral arteries. The subscapular artery is divided into the circumflex scapular and the thoracodorsal arteries. Our work presents a previously undescribed branching pattern of the right subscapular artery. It branched into the thoracodorsal, the circumflex scapular, the profunda brachii, and the anterior and posterior circumflex humeral arteries. The profunda brachii artery was 0.4 cm in diameter and ran inferiorly to the humeromuscular canal. No branches of the profunda brachii artery were found in the superior part of the arm before entering the humeromuscular canal. No variations in the other parts of the right axillary artery and of the left axillary artery were discovered. The described branching pattern of the subscapular artery can be important and essential for surgeons and radiologists.

Special report of the first Australasian Diagnostic Error in Medicine Conference from 23 to 25 May, 2017.

We attended the first Australasian Diagnostic Error in Medicine Conference (Aus DEM) in Melbourne from 23 to 25 May, 2017. We believe hosting the DEM conference in Japan is vital in promoting diagnostic error prevention initiatives in our region. We hope all the stakeholders in health care will join the DEM conference to be hosted in our country to address issues surrounding diagnostic errors.

Defining the critical role of nurses in diagnostic error prevention: a conceptual framework and a call to action.

Nurses have always been involved in the diagnostic process, but there remains a pervasive view across physicians, nurses, and allied health professionals that medical diagnosis is solely a physician responsibility. There is an urgent need to adjust this view and for nurses to take part in leading efforts addressing diagnostic errors. The purpose of this article is to define a framework for nursing engagement in the diagnostic process that can serve as a catalyst for nurses to engage in eliminating preventable harms from diagnostic error. We offer a conceptual model to formalize and expand nurses' engagement in the diagnostic process through education, maximize effectiveness of interprofessional teamwork and communication through culture change, and leverage the nursing mission to empower patients to become active members of the diagnostic team. We describe the primary barriers, including culture, education, operations, and regulations, to nurses participating as full, equal members of the diagnostic team, and illustrate our approach to addressing these barriers. Nurses already play a major role in diagnosis and increasingly take ownership of this role, removing barriers will strengthen nurses' ability to be equal, integral diagnostic team members. This model should serve as a foundation for increasing the role of the nurse in the diagnostic process, and calling nurses to take action in leading efforts to reduce diagnostic error.

Infectious diseases with changing geography

Background: Human migration during the last decades and the subsequent spreading of infectious diseases beyond the boundaries of their usual habitat changed the diagnostic philosophy of infectionists and epidemiologists. We present two cases treated in our clinic with the diagnoses of visceral leishmaniasis and malaria associated with Crimean hemorrhagic fever. Methods & Materials: Clinical observation, epidemiological investigation, laboratory testing with serological and virological diagnostics were done on the two patients. Results: Case 1 - A 33 year old man was treated with serologically proved diagnosis, ELISA (+) of visceral leishmaniasis. The disease started in Tavira, Portugal with fever (up to 39oC) and headache. Objective status: the patient was intoxicated with, anemic syndrome, splenohepatomegaly, Hb-94 g/l, Leuc.-1.95.109/l, Plt-44.109/l. He was treated for 28 days with meglumine antimoniate (amp. 5 ml. daily) combined with allopurinol and ketoconazole. After dynamic tracking the patient was clinically healthy, with normal laboratory indices. Case 2 – A 39 year old man became ill 5 days after he return in Bulgaria from Zambia with symptoms of fever, headache, myalgia, vomiting and blood and mucous in diarrhea. Objective status: the patient was in severe state, intoxicated with craniopharyngeal and hemorrhagic syndromes, hepatosplenomegaly. Laboratory tests showed anemia, thrombocytopenia and uremia. The thick and thin smears proved tropical malaria with high number of plasmodium falciparum (224 000/μl). The PCR was positive for CCHF. He was treated with hyperimmune globulin, artequin and hemostatic drugs. The rarely observed association between the two diseases led to potentiation amid immunodepression with the development of cerebral complications and multiple organ failure with a fatal end. Conclusion: The early diagnosis and adequate therapy of visceral leishmaniasis are crucial for its favorite outcome and the prevention of diagnostic errors with unpredictable effects. The most important measures are: WHO Global Malaria Programme, health education, medicine prophylactics of endemically exposed individuals, detailed epidemiological anamnesis and early etiological treatment after the onset of symptoms.

Unilateral Rectus Sternalis Muscle: Rare But Normal Anatomical Variant of Anterior Chest Wall Musculature

Rectus Sternalis muscle, an uncommon anatomical variant of the chest wall musculature, is regularly present in lower animals and is occasionally detected in humans. Lack of acquaintance of the clinicians with this muscle variant may cause negative changes in prognosis of patient. The anatomical and embryological details of Rectus Sternalis muscle in this article may help clinicians in interventional procedures, in prevention of diagnostic errors and in avoiding complications during any surgery which is done in the pectoral region. This was a cadaveric study which was conducted as a pilot study, to know the baseline information about the incidence of Rectus Sternalis muscle among cadavers in Indian region. During a period of three years, 30 properly embalmed cadavers of Indian origin were dissected in dissection hall of Anatomy Department, S.M.S. Medical College (Jaipur, Rajasthan) during routine dissections, which is a part of medical education. Dissections of pectoral regions of these 30 cadavers were performed, to know the presence of Rectus Sternalis muscle. Observation and Result: Rectus Sternalis muscle was found only in one cadaver, as a vertical strip of muscle in the anterior chest wall musculature. It was present unilaterally at right-side in anterior chest wall, superficial to pectoralis major muscle. Present study provides the initial estimates towards baseline information about the incidence of Rectus Sternalis, which was 3.3% among the cadavers of Indian origin in this study. Rectus Sternalis is a rare but a normal anatomical variant in the anterior chest wall musculature and knowledge on it is important, for interventional and diagnostic procedures which are related to this region.

System-related interventions to reduce diagnostic errors: a narrative review

BackgroundDiagnostic errors (missed, delayed or wrong diagnosis) have recently gained attention and are associated with significant preventable morbidity and mortality. The authors reviewed the recent literature and identified interventions that...

Misleading one detail: a preventable mode of diagnostic error?

Despite advances in our understanding of cognitive biases in clinical practice, little is known about correction or prevention of diagnostic errors. The presence of a single misleading detail may lead clinicians down a cognitive and actual path toward an incorrect diagnosis. In a large teaching hospital, we surveyed 51 attending doctors in internal medicine, presenting each with 10 clinical vignettes and soliciting their diagnosis of the condition leading to the presentation. Each of the 10 clinical cases included a single misleading detail. 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 improve by warning doctors about potentially misleading information. Asking doctors to identify a leading diagnostic detail and then to formulate an alternative diagnosis after omission of the detail, significantly reduced diagnostic error rate by nearly 50%. Systematic re-examination of leading diagnostic clues may help to reduce errors in diagnosis.

Reducing Diagnostic Errors through Effective Communication: Harnessing the Power of Information Technology

Diagnostic errors are poorly understood despite being a frequent cause of medical errors. Recent efforts have aimed to advance the "basic science" of diagnostic error prevention by tracing errors to their most basic origins. Although a refined theory of diagnostic error prevention will take years to formulate, we focus on communication breakdown, a major contributor to diagnostic errors and an increasingly recognized preventable factor in medical mishaps. We describe a comprehensive framework that integrates the potential sources of communication breakdowns within the diagnostic process and identifies vulnerable steps in the diagnostic process where various types of communication breakdowns can precipitate error. We then discuss potential information technology-based interventions that may have efficacy in preventing one or more forms of these breakdowns. These possible intervention strategies include using new technologies to enhance communication between health providers and health systems, improve patient involvement, and facilitate management of information in the medical record.

Cognitive errors in diagnosis: instantiation, classification, and consequences.

To identify diagnostic errors caused by faulty clinical cognition, we analyzed 40 consecutive transcripts of problem-solving exercises published in a pedagogic series of clinical reasoning. The analysis disclosed multiple errors in cognition and produced a provisional classification of these errors based on a framework derived from cognitive science. Faults in cognition were identified in all steps of the diagnostic process, including triggering, context formulation, information gathering and processing, and verification. We instantiated each type of error by providing detailed specific examples, and identified the consequences of each error. We conclude that cognitive errors can be identified and classified, that they can produce serious morbidity, and that a classification of cognitive errors is a step toward a deeper understanding of the epidemiology, causes, and prevention of diagnostic errors.