Eliot N. Mostow, MD, MPH, talks with a session attendee at the end of Saturday’s Forum about reducing errors in medical practices.
Taking a cue from how dermatologists work to diagnose, treat, and prevent problems for their patients, Eliot N. Mostow, MD, MPH, and Stephen Helms, MD, helped Annual Meeting attendees think about ways to diagnose, treat, and prevent errors in their medical practices during a Saturday Forum.
“Experts agree that nobody is perfect. In our dermatology practices, we all try to do great jobs. As good as we all think we are, we are not always going to get 100 percent. It’s about taking a few minutes of your time in your days to come to think about what’s happening in your practices and in your heads,” said Eliot Mostow, MD, professor and chair of dermatology at Northeast Ohio Medical School, Rootstown, and assistant professor of dermatology at Case Western Reserve University School of Medicine, Cleveland.
The speakers sought to help attendees identify examples of iatrogenic problems, including diagnostic errors, and develop systems within their practices to reduce such problems.
In the 1980s, the airline industry endeavored to overcome human errors that caused 70 to 80 percent of commercial aviation accidents by developing checklists, avoiding decision-making pitfalls, and maintaining continuous quality improvement processes.
With evidence-based strategies, physicians can improve efficiencies and hold medical errors to a minimum.
While the Institute of Medicine’s landmark reports on medical errors caught the nation’s attention in 1999 and 2000, medicine has become much more complex and the number of errors remains high. In 2010, the office of the Inspector General for the Department of Health and Human Services said that bad hospital care contributed to the deaths of 180,000 patients in Medicare alone in a given year. A 2013 Journal of Patient Safety article noted that between 210,000 and 440,000 patients each year who go to the hospital for care suffer some type of preventable harm that contributes to their deaths.
“We’re going to make errors. I think once we get past that, then we can really analyze this subject. The consensus of the literature is that most errors are cognitive and result from the application of one or more cognitive biases,” said Dr. Helms, professor of dermatology at the University of Mississippi Medical Center, Jackson.
While challenges for physicians may seem insurmountable, many errors are preventable, said Dr. Helms, adding this quote from Benjamin Franklin: “By failing to prepare, you are preparing to fail.”
For Drs. Mostow and Helms, the unifying themes are communication by the team and the use of checklists.
“It’s thinking about your day. What are all the steps that happen so you can create a map and say, ‘This has a potential for a problem. Now I’m going to try to intervene on this particular step or that step,’” Dr. Mostow said.
Dr. Helms added that the majority of errors are due to flaws in physician thinking, not technical mistakes. “Sometimes you can get off on a tangent and one thing just leads to another,” he said.
A simple way to think about cognitive errors is through three main types: anchoring, attribution, and availability.
In anchoring errors, individuals ascribe to shortcut thinking, don’t consider multiple possibilities, quickly and firmly latch onto a single diagnosis, and use confirmation, which is to see only the landmarks one expects to see and neglect those that contradict what one does not see.
Attribution errors are when a person attributes signs and symptoms to the wrong cause, guides thinking by a prototype, is affected by emotional factors, and fails to consider possibilities that contradict the prototype.
With availability errors, the tendency is to judge the likelihood of an event by the ease with which relevant examples come to mind.
Dr. Mostow suggested that physicians use Visual DX, a clinical diagnostic and management tool. Physicians can search by patient factors and develop a visual differential diagnosis.
He also pointed to a model where physicians:
- Plan: Identify and analyze the problem.
- Do: Develop and test a potential solution.
- Check: Measure how effective the test solution was and analyze whether it could be improved in any way.
- Act: Implement the improved solution fully.
“The fact is, you can have a bad day, your children upset you, or your wife or husband is mad at you,” Dr. Mostow said. “There are so many things that go into what goes on in our heads in terms of how we do things. We think we are all the same every day, but we’re not. There is a lot of potential for issues. We have to strive to do the best we can so we can reduce problems.”