Identification of factors associated with diagnostic error in primary care

Abstract

BackgroundMissed, delayed or incorrect diagnoses are considered to be diagnostic errors. The aim of this paper is to describe the methodology of a study to analyse cognitive aspects of the process by which primary care (PC) physicians diagnose dyspnoea. It examines the possible links between the use of heuristics, suboptimal cognitive acts and diagnostic errors, using Reason’s taxonomy of human error (slips, lapses, mistakes and violations). The influence of situational factors (professional experience, perceived overwork and fatigue) is also analysed.MethodsCohort study of new episodes of dyspnoea in patients receiving care from family physicians and residents at PC centres in Granada (Spain). With an initial expected diagnostic error rate of 20%, and a sampling error of 3%, 384 episodes of dyspnoea are calculated to be required. In addition to filling out the electronic medical record of the patients attended, each physician fills out 2 specially designed questionnaires about the diagnostic process performed in each case of dyspnoea. The first questionnaire includes questions on the physician’s initial diagnostic impression, the 3 most likely diagnoses (in order of likelihood), and the diagnosis reached after the initial medical history and physical examination. It also includes items on the physicians’ perceived overwork and fatigue during patient care. The second questionnaire records the confirmed diagnosis once it is reached. The complete diagnostic process is peer-reviewed to identify and classify the diagnostic errors. The possible use of heuristics of representativeness, availability, and anchoring and adjustment in each diagnostic process is also analysed. Each audit is reviewed with the physician responsible for the diagnostic process. Finally, logistic regression models are used to determine if there are differences in the diagnostic error variables based on the heuristics identified.DiscussionThis work sets out a new approach to studying the diagnostic decision-making process in PC, taking advantage of new technologies which allow immediate recording of the decision-making process.

Use of Heuristics during the clinical decision process from family physicians in real conditions.

“…The uncertainty of the problem at hand (especially in the context of PC), the limited time available and the cost involved in searching for information may result in a greater use of system 1 by physicians (30), opting for intuitive and heuristic decisions, allowing quick decisions to be made. In any case, the effect of unconscious thinking on clinical decision-making is contradictory,11 the evidence on the use of heuristics in medicine is very scarce and the instruments and operational definitions for their assessment are insufficiently validated (25,26,32). Most of the knowledge regarding clinical decision-making and the use of intuitive strategies is based on studies conducted under experimental conditions, using simulations or vignette assessment, which are unlikely to be representative of real-life clinical encounters (29).…”

“…Operational definition of the heuristics: For the operational approach to the use of the Representativeness and Availability heuristics, the previously published study protocol was used, which analyses the cognitive aspects of the diagnostic process of dyspnoea by primary care physicians (26), the definition of which is described below: Representativeness: the possible use of the representativeness heuristic is considered when the Confirmatory Diagnosis of dyspnoea coincides with the First Diagnostic Impression made by the physician when identifying a new episode of dyspnoea, before initiating any clinical intervention (anamnesis, physical examination, or request for diagnostic tests. It would form part of what has been called "gut feeling " (28) or "first diagnostic impression "(29), identifying the degree of similarity of the sample (the new case) with the population (the set of cases of that diagnosis).…”

Comprehensive process model of clinical information interaction in primary care: results of a “best-fit” framework synthesis

“…to simplify judgmental tasks." 175 Dozens of heuristics are commonly used in primary care. [175][176][177] Analytical approach.…”

“…175 Dozens of heuristics are commonly used in primary care. [175][176][177] Analytical approach. Analytical reasoning involves both using and generating assessments; hence, the line linking Boxes 5 and 6 is bidirectional.…”

Diagnostic error in family medicine

“…Zakonski obavezan skrining značajno bi smanjio broj zakašnjelih dijagnoza preventabilnih karcinoma. [3] Poznavanje dijagnostičkih algoritama za stanja i bolesti sa kojima se susrećemo u svakodnevnoj praksi nameće se kao imperativ za uspješan menadžment tima porodične medicine. Smjernice vodiča dobre kliničke prakse predstavljaju najznačajniji putokaz u odluci kada je vrijeme da samostalno preuzmemo brigu o pacijentu.…”