Reducing the Risk of Diagnostic Error in the COVID-19 Era

10.12788/3461 ◽  
2020 ◽  
Vol 15 (6) ◽  
pp. 363-366 ◽  
Author(s):  
Tejal K Gandhi ◽  
Hardeep Singh
Keyword(s):  
Clinical Decision Making ◽  
Clinical Manifestations ◽  
Diagnostic Errors ◽  
Psychological Safety ◽  
Clinical Decision ◽  
Diagnostic Error ◽  
Situational Factors ◽  
System Capacity ◽  
Care Processes ◽  
Stress Fatigue

As the death toll from the coronavirus disease 2019 (COVID-19) pandemic rapidly increases, the need to make a timely and accurate diagnosis has never been greater. Even before the pandemic, diagnostic errors (ie, missed, delayed, and incorrect diagnoses) had been one of the leading contributors to harm in health care.1 The COVID-19 pandemic is likely to increase the risk of such errors for several reasons. The disease itself is new and knowledge of its clinical manifestations is still evolving. Both physical and psychological safety of clinicians and health system capacity are compromised and can affect clinical decision-making.2 Situational factors such as staffing shortages and workarounds are more common, and clinicians in certain geographic areas are experiencing epic levels of stress, fatigue, and burnout. Finally, decisions in busy, chaotic and time-pressured healthcare systems with disrupted and/or newly designed care processes will be error prone.1

Avoiding anchoring bias in unexplained chronic pain: an unexpected diagnosis of synovial osteochondromatosis

2021 ◽  
Vol 14 (4) ◽  
pp. e240462
Author(s):  
Rehana Murani ◽  
Ranita Harpreet Kaur Manocha
Keyword(s):  
Decision Making ◽  
Chronic Pain ◽  
Clinical Decision Making ◽  
Clinical Decision ◽  
Diagnostic Error ◽  
Synovial Osteochondromatosis ◽  
Unexplained Pain ◽  
Anchoring Bias ◽  
History Of ◽  
Yellow Flags

Unconscious biases may influence clinical decision making, leading to diagnostic error. Anchoring bias occurs when a physician relies too heavily on the initial data received. We present a 57-year-old man with a 3-year history of unexplained right thigh pain who was referred to a physiatry clinic for suggestions on managing presumed non-organic pain. The patient had previously been assessed by numerous specialists and had undergone several imaging investigations, with no identifiable cause for his pain. Physical examination was challenging and there were several ‘yellow flags’ on history. A thorough reconsideration of the possible diagnoses led to the discovery of hip synovial osteochondromatosis as the cause for his symptoms. Over-reliance on the referral information may have led to this diagnosis being missed. In patients with unexplained pain, it is important to be aware of anchoring bias in order to avoid missing rare diagnoses.

Hypertension masquerading as Pediatric Cardiomyopathy: an exercise in cognitive biases

2021 ◽  
pp. 1-3
Author(s):  
Asim Al Balushi ◽  
Chentel Cunningham ◽  
Manjula Gowrishankar ◽  
Jennifer Conway ◽  
Michael Khoury
Keyword(s):  
Decision Making ◽  
Rare Disease ◽  
Clinical Decision Making ◽  
Cognitive Biases ◽  
Newborn Infants ◽  
Diagnostic Errors ◽  
Clinical Decision ◽  
Adverse Outcomes ◽  
Renal Disorders ◽  
Pediatric Cardiomyopathy

Abstract Heuristics and cognitive biases constantly influence clinical decision-making and often facilitate judgements under uncertainty. They can frequently, however, lead to diagnostic errors and adverse outcomes, particularly when considering rare disease processes that have common, masquerading presentations. Herein, we present two such cases of newborn infants with hypertensive renal disorders that were initially thought to have cardiomyopathy.

scholarly journals A Cognitive Autopsy Approach towards Understanding Diagnostic Failure

2020 ◽  
Author(s):  
Pat Croskerry ◽  
Samuel Campbell
Keyword(s):  
Decision Making ◽  
Clinical Decision Making ◽  
Clinical Performance ◽  
Critical Role ◽  
Clinical Decision ◽  
Diagnostic Error ◽  
Diagnostic Process ◽  
Base Line ◽  
Root Cause ◽  
Knowledge Based

Diagnostic failure has emerged as one of the most significant threats to patient safety, and it is important to understand the antecedents of such failures. A consensus has developed in the literature that the majority are due to individual or system factors or some combination of the two. A major source of variance in individual clinical performance is due to cognitive and affective biases, however, their role in clinical decision making has been difficult to assess partly because they are difficult to investigate experimentally. A significant drawback has been that experimental manipulations appear to confound assessment of the context surrounding the diagnostic process itself. The present qualitative study uses a detailed narrative account of selected actual cases of diagnostic error to explore the effect of biases in the ‘real world’ emergency medicine (EM) context. Thirty anonymized EM cases were analysed in depth through a process of root cause analysis that included an assessment of error producing conditions, knowledge-based errors, and how clinicians were thinking and deciding during each case. A prominent feature of the study was the identification of specific cognitive and affective biases – through a process called cognitive autopsy. The cases covered a broad range of diagnoses across a wide variety of disciplines. A total of 24 discrete cognitive and affective biases that contributed to misdiagnosis were identified and their incidence recorded. 5-6 biases were detected per case, and observed on 168 occasions across the 30 cases. Thirteen error-producing conditions (EPCs) were identified. Knowledge-based errors were rare, occurring in only 5 definite instances. The ordinal position in which biases appeared in the diagnostic process was recorded. This study provides a base-line for understanding the critical role that biases play in clinical decision making and sheds light on important aspects of the diagnostic process.

scholarly journals Clinical manifestations and laboratory results of 61 children with infectious mononucleosis

2020 ◽  
Vol 48 (10) ◽  
pp. 030006052092455
Author(s):  
Yanming Wu ◽  
Suli Ma ◽  
Lingjun Zhang ◽  
Daoming Zu ◽  
Fangjin Gu ◽  
...  
Keyword(s):  
Nasal Obstruction ◽  
Infectious Mononucleosis ◽  
Clinical Decision Making ◽  
Disease Onset ◽  
Clinical Manifestations ◽  
Cervical Lymphadenopathy ◽  
Clinical Decision ◽  
Preschool Age ◽  
Older Children ◽  
Laboratory Results

Objective To investigate the clinical manifestations of infectious mononucleosis in children of different ages. Methods Clinical data from pediatric patients with infectious mononucleosis admitted from May 2015 to April 2019 were retrospectively analyzed. Patients were stratified into three groups (age 1–3 years, 4–6 years, and 7–14 years) for analysis of clinical and laboratory results. Results Data from 61 patients (male:female ratio 1.18:1) aged 5.15 ± 2.93 years (mean ± standard deviation; range: 1–14 years) were analyzed. Infectious mononucleosis occurred throughout the year and the main clinical manifestations were fever (98.3%), tonsillitis (100%), tonsillar white exudate (83.6%), cervical lymphadenopathy (98.3%), hepatomegaly (37.7%), splenomegaly (42.6%), eyelid edema (41.0%), and nasal obstruction (49.2%). Disease onset was most common during early childhood (37.7%) and at preschool age (37.7%). Younger children had more obvious symptoms of nasal obstruction and older children had more significant elevations of alanine aminotransferase and higher percentages of atypical lymphocytes. Conclusion The clinical manifestations of infectious mononucleosis in children differed by age. These associations required attention for clinical decision making.

scholarly journals Peer Discussion Decreases Practice Intensity and Increases Certainty in Clinical Decision-Making Among Internal Medicine Residents

2021 ◽  
Vol 13 (3) ◽  
pp. 371-376
Author(s):  
Neha Bansal Etherington ◽  
Caitlin Clancy ◽  
R. Benson Jones ◽  
C. Jessica Dine ◽  
Gretchen Diemer
Keyword(s):  
Internal Medicine ◽  
Decision Making ◽  
Clinical Decision Making ◽  
Clinical Decision ◽  
Diagnostic Error ◽  
Mean Difference ◽  
Internal Medicine Residents ◽  
Average Group ◽  
Peer Discussion ◽  
Individual Scores

ABSTRACT Background Team-based decision-making has been shown to reduce diagnostic error, increase clinical certainty, and decrease adverse events. Objective This study aimed to assess the effect of peer discussion on resident practice intensity (PI) and clinical certainty (CC). Methods A vignette-based instrument was adapted to measure PI, defined as the likelihood of ordering additional diagnostic tests, consultations or empiric treatment, and CC. Internal medicine residents at 7 programs in the Philadelphia area from April 2018 to June 2019 were eligible for inclusion in the study. Participants formed groups and completed each item of the instrument individually and as a group with time for peer discussion in between individual and group responses. Predicted group PI and CC scores were compared with measured group PI and CC scores, respectively, using paired t testing. Results Sixty-nine groups participated in the study (response rate 34%, average group size 2.88). The measured group PI score (2.29, SD = 0.23) was significantly lower than the predicted group PI score (2.33, SD = 0.22) with a mean difference of 0.04 (SD = 0.10; 95% CI 0.02–0.07; P = .0002). The measured group CC score (0.493, SD = 0.164) was significantly higher than the predicted group CC score (0.475, SD = 0.136) with a mean difference of 0.018 (SD = 0.073; 95% CI 0.0006–0.0356; P = .022). Conclusions In this multicenter study of resident PI, peer discussion reduced PI and increased CC more than would be expected from averaging group members' individual scores.

scholarly journals Review of published systematic reviews and meta-analyses on COVID-19

2020 ◽  
Author(s):  
Ezzeldin Ibrahim ◽  
Nasrien E Ibrahim
Keyword(s):  
Systematic Reviews ◽  
Clinical Decision Making ◽  
Treatment Guidelines ◽  
Clinical Manifestations ◽  
Clinical Decision ◽  
Rapid Spread ◽  
The World ◽  
Scientific Accuracy ◽  
Meta Analyses ◽  
And Control

Purpose: The rapid spread of the COVID-19 pandemic has prompted researchers from all over the world to share their experience. The results were numerous reports with variable quality. The latter has provided an impetus to examine all published meta-analyses and systematic reviews on COVID-19 to date to examine available evidence. Methods: Using predefined selection criteria, a literature search identified 43 eligible meta-analyses and/or systematic reviews. Results: Most (N=17) studies addressed clinical manifestations and associated comorbidity, 6 studies addressed clinical manifestations in pregnant women and younger individuals, 8 studies addressed diagnostic data, 9 studies addressed various interventions, and 9 studies addressed prevention and control. The number of studies included in the various systemic reviews and meta-analyses ranged from 2 to 89. While there were some similarities and consistency for some findings, e.g. the relation between comorbidities and disease severity, we also noted occasionally conflicting data. Conclusion: As more data are collected from patients infected with COVID-19 all over the world, more studies will undoubtedly be published and attention to scientific accuracy in the performance of trials must be exercised to inform clinical decision-making and treatment guidelines.

scholarly journals Standardization of enzyme-linked immunosorbent assays for serosurveys of the SARS-CoV-2 pandemic using clinical and at-home blood sampling

2020 ◽  
Author(s):  
Carleen Klumpp-Thomas ◽  
Heather Kalish ◽  
Matthew Drew ◽  
Sally Hunsberger ◽  
Kelly Snead ◽  
...  
Keyword(s):  
Influenza A ◽  
Clinical Decision Making ◽  
Diagnostic Errors ◽  
Clinical Decision ◽  
The United States ◽  
Cross Reactivity ◽  
Blood Sampling ◽  
Clinical Testing ◽  
Correlates Of Protection ◽  
Influenza A H1n1

ABSTRACTThe extent of SARS-CoV-2 infection throughout the United States population is currently unknown. High quality serology is a key tool to understanding the spread of infection, immunity against the virus, and correlates of protection. Limited validation and testing of serology assays used for serosurveys can lead to unreliable or misleading data, and clinical testing using such unvalidated assays can lead to medically costly diagnostic errors and improperly informed public health decisions. Estimating prevalence and clinical decision making is highly dependent on specificity. Here, we present an optimized ELISA-based serology protocol from antigen production to data analysis. This protocol defines thresholds for IgG and IgM for determination of seropositivity with estimated specificity well above 99%. Validation was performed using both traditionally collected serum and dried blood on mail-in blood sampling kits, using archival (pre-2019) negative controls and known PCR-diagnosed positive patient controls. Minimal cross-reactivity was observed for the spike proteins of MERS, SARS1, OC43 and HKU1 viruses and no cross reactivity was observed with anti-influenza A H1N1 HAI titer during validation. This strategy is highly specific and is designed to provide good estimates of seroprevalence of SARS-CoV-2 seropositivity in a population, providing specific and reliable data from serosurveys and clinical testing which can be used to better evaluate and understand SARS-CoV-2 immunity and correlates of protection.

Inflammatory Myofibroblastic Tumor of the Urinary System on Computed Tomography at a High-Volume Institution in China

2020 ◽  
Vol 104 (11-12) ◽  
pp. 960-967
Author(s):  
Bo Chen ◽  
Shuang Li ◽  
Xin Fang ◽  
He Xu ◽  
Jianqun Yu ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Clinical Decision Making ◽  
Clinical Manifestations ◽  
High Volume ◽  
Clinical Decision ◽  
Imaging Features ◽  
Urinary System ◽  
Eligibility Criteria ◽  
Enhanced Computed Tomography

<b><i>Objective:</i></b> Inflammatory myofibroblastic tumors (IMTs) of the urinary system are relatively rare and often misdiagnosed. We aimed to summarize and analyze the clinical manifestations, imaging features, management, and follow-up of renal and bladder IMTs. <b><i>Methods:</i></b> In this retrospective study, 22 patients with IMT pathologically verified between 2009 and 2018 were included. Epidemiologic, clinical, pathologic, and imaging findings were recorded. Tumor size, location, and shape were analyzed and summarized. <b><i>Results:</i></b> There were 22 patients with a median age of 45 years (range: 20–74), including 14 patients with renal IMT and 8 patients with bladder IMT, who met the eligibility criteria. In 21 patients, IMT appeared as a single lesion, whereas 1 patient showed bilateral renal lesions. Surgical resection was the sole therapy, and follow-up information was acquired from 13 individuals with no evidence of recurrence or metastasis. In our study, a slightly hypodense or isodense homogeneous tumor with a clear boundary was more often seen. On contrast-enhanced computed tomography (CT), they were often manifesting as a slightly heterogeneous enhancement. <b><i>Conclusions:</i></b> The nature of IMTs might cause a lack of generalizability. However, it will be useful to know that there are various CT demonstrations of IMTs. CT images are useful for the detection, location, and characterization of urinary IMTs, which can help in better clinical decision-making and can also be an optimal imaging technique for follow-up.

Sign in / Sign up

Export Citation Format

Share Document