Replacing Hindsight With Insight: Toward Better Understanding of Diagnostic Failures

Assessing Diagnostic Reasoning: A Consensus Statement Summarizing Theory, Practice, and Future Needs

“…However, hospital discharge diagnoses, the current criterion standard against which ED diagnoses are measured, suffer from hindsight bias. 11 Actual patient outcomes may be the best measure of diagnostic reasoning. However, current measures of quality (i.e., core measures) are confounded by many elements outside of an EP's control and may not correlate with the accuracy of diagnostic reasoning.…”

“…8 However, the retrospective analyses used in all of these studies are prone to substantial hindsight bias, where further clinical information, and the evolution of patients' symptoms were unavailable at the time of ED diagnosis. 11 In May 2012, Academic Emergency Medicine hosted a consensus conference entitled "Education Research in Emergency Medicine: Opportunities, Challenges, and Strategies for Success," with the goals of defining research agendas that address the measurement gaps in EM education and building infrastructure for collaboration in these domains. This article reports on the findings of the diagnostic reasoning assessment breakout session.…”

What can be done to increase the use of diagnostic decision support systems?

“…That is, the typical approach of generating and confirming diagnoses fairly rapidly, will, most of the time, as described above, yield a correct diagnosis. Wears and Nemeth have commented that errors, diagnostic and otherwise, are often obvious only in hindsight [19]. In fact, if a physician arrives at a diagnosis quickly with only a few pieces of the potentially available patient data, if the diagnosis is correct, the physician is hailed as a great diagnostician, but if it is wrong, it is considered premature closure.…”

Use of an Expedited Review Tool to Screen for Prior Diagnostic Error in Emergency Department Patients

“…Claims for misdiagnosis are the leading cause of malpractice cases [3][4][5][6][7], but determining their true incidence remains difficult for multiple reasons. These include lack of agreement on definitions for diagnostic errors, or even whether these should be described more neutrally, as in "diagnostic discrepancies"; the subjective nature of determining whether a diagnosis could and should have been made earlier, with significant concerns regarding hindsight and outcome bias [8]; poor feedback systems, where diagnoses made in one encounter frequently are not connected to prior or future patient outcomes; the insensitivity of traditional approaches such as random case review, autopsy review, and malpractice claims in finding diagnostic error; and the typically time-intensive process of reviewing patient charts to identify diagnosis errors or delays [9]. This last barrier limits the extensive review of records in research, with one study of diagnostic errors reporting a mean review time of 1.4 hours per record [5].…”

“…Too, we were dependent on information and reasoning documented in the EHR, therefore falsely flagging instances where a clinician considered, but did not document, the ultimate diagnosis. Conversely, there may be missed diagnoses still missed on repeat presentations.We also recognize that rating a missed or delayed diagnosis involves subjective judgment, and there are appreciable concerns that reviewers will consistently overestimate the degree to which a diagnosis was truly missed given the constraints of the initial interaction [8,20]. We attempted to control for this by using explicit criteria as well as having a second reviewer for all cases with any possibility of missed diagnoses, plus a random sample of the negative subset of cases.…”