News :Avoiding Common Medical Thinking Errors

Posted on Monday, November 24, 2008

Medical errors are the eighth leading cause of death in the U.S., killing nearly 100,000 people a year, according to the Institute of Medicine of the National Academy of Sciences. Additional medical errors harm another 1.5 million patients. The annual price tag for preventable patient injury resulting from medical mistakes is in excess of $30 billion. As the principal providers of primary health care, nurses are in a unique position to significantly decrease the likelihood of a medical error occurring, ensuring that an optimal level of patient safety and security in the care they are receiving is maintained.

How medical errors occur
It’s only on rare occasion that medical errors occur due to carelessness or caregiver misconduct. Some are due to technical problems or laboratory errors, but the bulk of medical errors are caused by simple human failing, most often resulting from:

• Poor communication between staff
• Indecipherable handwriting on charts or prescriptions
• Lookalike drug names
• Fatigue due to long shift hours
• Heavy caseloads that pressure medical personnel to minimize the time spent with each patient
• Inadequate staff training in facility procedures and lack of procedural standardization across regional facilities

But while all of these factors increase the chance of a medical error occurring, a surprising number of medical mistakes are caused by thinking errors.

“About 15 percent of all patients are misdiagnosed, and half of those face serious harm, even death, because of the error,” says noted Physician, researcher, and Harvard Medical School professor Dr. Jerome Groopman in the September/October 2008 issue of AARP magazine.

About 80 percent of all misdiagnoses are due to cognitive errors. “Contrary to the general impression that most misdiagnoses result from a technical foul-up, such as mislabeling someone’s X-ray or mixing up a blood specimen in the laboratory, most cases are due to mistakes in the mind of the doctor,” asserts Groopman.

When making a diagnosis, doctors look for evidence of patterns in physical examination results, symptoms, and laboratory tests, then search their cranial catalog of diseases for matching patterns. Groopman believes that, too often, doctors base their diagnosis on incomplete or misleading information, or jump to an incorrect conclusion.

Studies show that both the patient and doctor contribute to the problem. Patients may be uncomfortable discussing certain symptoms and fail to mention a critical indicator. Under the stress of visiting the doctor, patients often fail to remember all symptoms or recognize the possible connection to a past event. Overscheduled doctors may jump to a ready conclusion and cut off a patient’s recital before differentiating symptoms are mentioned.

The unique experience of each individual patient and atypical cases can further complicate the pattern recognition process. “Most significant is how the doctor selects the clinical elements, weighs their importance, and arranges them in his or her mind, a process that can result in several different patterns, leading to quite different diagnoses,” explains Groopman.

Three major cognitive mistakes are at the root of most medical misdiagnoses:

• Anchoring: the tendency to focus on the first definitive symptom. While such “snap judgments” are often accurate, they can cause medical personnel to ignore other possibilities.
• Availability: the use of recently remembered experience to explain the current case. Because the brain focuses most easily on recent events, similarities between recent and current cases can lead medical personnel to erroneous assumptions.
• Attribution: the human inclination to stereotype people – often seniors — and mentally assign a diagnosis based on behavior. Dismissing patients as “hypochondriacs” or “complainers” can result in medical personnel overlooking signs of illness or disease.

The phenomenon isn’t limited to Physicians. Nurses and nursing assistants, who make up 54 percent of U.S. healthcare workers, are just as prone to making the same mistakes. In a growing number of healthcare settings, including home healthcare, hospice, college infirmaries, urgent care centers, and pharmacy clinics, nurses are becoming the principal providers of primary healthcare. Increasingly, nurses and nurse assistants are responsible for making immediate decisions about a patient’s care.

To prevent cognitive thinking errors, Groopman suggests medical personnel ask themselves three important questions:

• What else could it be?
• Could two things be going on to explain the patient’s symptoms?
• Is there anything in the patient’s history, physical exam, lab findings or other tests that doesn’t support the working diagnosis?

The answers to these questions can help medical personnel to either confirm or re-evaluate their working diagnosis. Nurses are in a unique position to guard patients against cognitive thinking errors. They collect the vital data that helps determine a diagnosis: medical history, symptoms, behavior, drug list, etc. They chat with and observe patients who are often more comfortable confiding in a nurse. They check and administer doctors’ orders, go over instructions and prescriptions with patients, answer questions, demonstrate care procedures, and educate. Nurses are a patient’s first, and last, line of defense against medical errors.