When errors happen in the hospital, we often blame the doctor or the system. We never think about how both these forces may act together. This is especially true when a doctor gets a diagnosis wrong. In a recent study published in Diagnosis, the authors examine how system and cognitive factors may interact to cause diagnostic errors.
By Ashwin Gupta
Traditionally, scientific research has examined systems-based (i.e., lack of standardized policy, discontinuous care, and interruptions) and cognitive-based (i.e., anchoring or availability bias) contributions to diagnostic error as discrete entities.
Using observations of inpatient medicine teams, focus groups and interviews of doctors at two affiliated academic medical centres, the study authors examined when both of these factors coincided, or when one led to the other. Cognitive categories were derived based on a previously published taxonomy and differentiated into factors contributing to faulty data gathering, faulty data processing, faulty data verification, and those spanning multiple cognitive domains.
Challenges with communication, both interdisciplinary communication and communication within the electronic medical record, were felt to contribute to faulty data gathering. Organizational structures within the hospital, for example the tendency for consulting services to operate in silos, promoted faulty information processing.
“The systems don’t help physicians make good decisions”
Frequent care handoffs contributed to faulty data verification. Finally, interruptions, time constraints and a cluttered physical environment were noted to negative impact multiple cognitive domains.
“When doctors make mistakes, we often think that the physician could have done better. The truth is – the systems often don’t help physicians make good decisions,” says Dr Vineet Chopra, the studies’ primary investigator.
So, how can these systems-turned-cognitive errors be addressed? The authors suggest several interventions that they feel warrant further evaluation. For example, within oncology, cancer tumour boards, which put oncologists, pathologists, radiation specialists and surgeons together in the same room to discuss a case, have resulted in improvements in diagnosis, evaluation and treatment in part through alleviation of system’s challenges such as difficult communication and care coordination.
Redesigning patient teams
In the same respect, the authors suggest that “diagnosis boards” may have similar impact, particularly in the cases of challenging diagnoses. Other recommendations include redesigning how teams round on patients, with separation between those rounding on patients already admitted to the hospital and those who are newly admitted through the emergency department. Rethinking the timing of formal didactic learning amongst medical learners, and redesigning the physical space in which diagnosis occurs.
Efforts to address diagnostic errors must recognize the overlap between systems- and cognitive-factors and interventions aimed at concurrently addressing both factors may result in greater success.
Read the Free Access original article here
Ashwin Gupta, Molly Harrod, Martha Quinn, Milisa Manojlovich, Karen E. Fowler, Hardeep Singh, Sanjay Saint, Vineet Chopra: Mind the overlap: how system problems contribute to cognitive failure and diagnostic errors. 14.07.2018