Safe Diagnosis

Toward a Patient Centred NHS Presentation to the Academy of Royal Medical Colleges at the Royal College of Surgeons 13/9/05 Nick Green Patient Public Involvement Forum Organisation Reducing Error and Delay http://www.ppif.org.uk

Why am I qualified to talk about this?

The consulting cybernetician Decision making under uncertainty motivates cybernetics General Management Heuristic reduces error Error Detection and Correction Change when policy fails Alerting, Modelling and Real Time Audit The Body Project: to understand and catalogue all physiological and pathophysiological processes

Background Lethal Medical Accidents

NPSA 840 patients died
(First Annual Report 2005)

Dr Foster estimates 40,000 died

(BMJ 2004;329:369)

Rath from US data150-200,000 died

(Dr. Rath Health Foundation 151 refs)

"Compared with the transport industry, the number of errors causing very high levels of death is extraordinary." Roger Taylor, research director of Dr Foster

Deaths
In 2004 514,250 died in UK and Wales About half in hospital (BMJ. 2004 May 22; 328(7450): 12351236 ) Worst case: 1 in 5 die without diagnostic or treatment error Best case 19 out of 20 die without diagnostic error Hospital death rates are reducing by 2.6% per year (B. Jarman, The quality of care in hospitals The Journal of the Royal College of Physicians of London 34,Jan/Feb 2000)

Life expectancy is increasing

Life expectancy has increased 1 year in every 4 since 1981. 1 day every 4. Why?

Are treatments improving at this rate?

ONS Life Expectancy 2004 http://www.statistics.gov.uk/CCI/nugget.asp?ID=881&Pos=1&ColRank=1&Rank=374

Causes of Death

ONS Life Expectancy 2004 http://www.statistics.gov.uk/CCI/nugget.asp?ID=881&Pos=1&ColRank=1&Rank=374

Concurrent Interacting Processes

Virus Disease

Ear

Musculoskeletal Blood Lymph Marrow

The Nomencleture of Disease HMSO 8th edition

Endocrine

The schoolboy howler

Patient presents anxious may have disease with back ground rate of 1 in 1000 Diagnostic test has 95% true positive rate Result positive What are my chances Doc? In fact its 50 to 1 you are ok! One test is not enough

Doctor Foster
Only 276,514 errors were recorded in English hospitals in 2004 but the National Patient Safety Agency (NSPA) puts the true figure at closer to 900,000 (Chief Medical Officer). Approximately 25 per cent of errors occur during surgery 25 per cent in diagnosis or pre-care: more than 200,000 in a year
http://home.drfoster.co.uk/news_items/1309/The Times 13 08 04.pdf

Half of all mistakes are made during ward treatment from inadequate nutrition to incorrect dose of medication

The Patient Model

Gold Standard: Is the death Certificate Correct?
Diagnose Treat Outcome

10-20,000 diseases :

14-15 yes/no unambiguous questions could define it if correctly answered. Getting these questions correctly answered is the skill of correct diagnosis.

Sington and Cottrell J Clin Pathol 2002;55:499502

Medical error reporting must take necropsy data into
account Letter: BMJ 2001;323:511

47% of Death Certificates correct for hospital deaths. Cardiovascular deaths 28% accurate Malignant deaths 35% over diagnosed
Rate of necropsy well below recommended 10% Necropsy is not random

Random Necropsy
If Sington and Cottrell were random then at least 50% of patients are treated for the wrong disease. If they are worst or hard cases then 5% of patients are treated for the wrong disease. Challenging Cases Prof John Senders estimates that iatrogenic disease affects between 5% and 50% of all patients.

Safety critical methods

Multiple independent teams Agreement Self-vetoing Proof of correctness Background error rate critical

Improving Diagnostic Accuracy

Assume Diagnosis 75% accurate. One doctor .75 chance of being right Two doctors .94 of being right Three doctors .98. Only 1 in 50 patients will be treated for the wrong disease. But only if independent! New history, tests and no prompting from patient on previous findings. Bonus for diagnosticians with novel finding?

Removing the Error from Diagnosis

300,000 250,000 200,000 Errors per million 150,000 diagnoses 100,000 50,000 1 2 3 4 5 6 7 8 9 10 Number of Independent Diagnoses

Assume no medical break throughs

No of Doctors 1 2 3 4 5 6 7 8 9 10

Errors per million 250,000 62,500 15,625 3,906 977 244 61 15 4 1

Starting with 1 in 4 diagnoses wrong with one diagnostician. Ten independent diagnoses, if they agree, will reduce diagnostic error to 1 in a million. Culture Change! Responsibility for error shared and better feedback for diagnosticians from colleagues

Even at 95% 5 Diagnosticians are needed to get to 1 in a million error

300,000

Diagnostic Agreement
75% error

Errors per million

75% error 250,000 62,500 15,625 3,906 977 244 61 15 4 1 80% error 200,000 40,000 8,000 1,600 320 64 13 3 1 90% error 100,000 10,000 1,000 100 10 1 95% error 50,000 2,500 125 6 1

250,000

200,000

80% 150,000

1 2 3 4 5 6 7 8

100,000 90%

50,000 95%

9
0 1 2 3 4 5 6 7 8 9 10

10

How to proceed?
Consultant General Physician Decision and Risk analysis More detail on Death Certificates: toxic burden Multiple blind diagnosis will need major changes to Clinical Practice. Likely savings make it feasible. Treatment costs halved?

Persistent Organic Pollutants

In water, food and homes In cadavers routine at random post mortem Synergystic toxicity: cocktail effect of sub-toxic exposure. Advance Directives Religious objectors may reconsider when they realise they will get poorer quality treatment.

Treatment errors
Wrong treatment Side effects of right treatment Right treatment wrongly given, incorrect dosages- surprisingly common CfH (NPfIT): complete real time audit of all interventions. Data mine of outcomes will quickly rival Pharmaceutical companies if recording outcomes mandatory

Body Knowledge Mining

When CfH established Shift NHS staff into fundamental research 2.3 in-patients per hospital doctor 1.8 nurses per patient 2 support staff per in-patient Raise status Elite in data capture Majority in checking and cataloguing

Decision

Development
Operation Audit Process

Regulation

Interactions of Actors Axioms

Context Perspective Responsible Respectable Amity Agreement Agreement-to-disagree (ATD) Purpose Unity not uniformity Faith Beginnings and Ends (CT) Eternally interacting (IA) Similarity and Difference Adaptation Evolution Generation Kinetic (IA) Kinematic (CT) Conservation of Meaningful Information Transfer both Permissive (Ap) and Imperative Application (Im) Informational openness and Organisational closure. Void and Not-Void

Coherence: the product of a process

Controlling the View of the Patient Care Record

Independent multiple diagnoses requires Same view of old history up to the new incident No view of history and tests by competing diagnosticians Further diagnostic encounters till risk reduced to some agreed standard level

We need a Tricorder!

Nick Green FCybS 13/9/05 Safe Diagnosis Contact: 020 7916 0285 nick_green@cybsoc.org

First PPIFO Conference for 2006

Speakers who have agreed to come or expressed interest include: Alexander Harris (Malpractice Solicitors) Dr Vernon Coleman (Decisions, Evidence and error) Dr Barrie Cottrell (Inaccuracy of Death Certificates) Dr Richard Fitton (NHS Connecting for Health) Dr Phil Hammond (Medical Culture) Prof Lewis Wolpert FRS (Biology and Safer Medicine) Sir Brian Jarman has suggested we approach the Chief Medical Officer on his plans for patient Safety and we think a senior DoH executive should be approached to talk about remedies for noncompliance with hand washing, cleaning contracts, queues, nursing standards etc. We are looking for co-sponsors for what we would like to be a free event. PPIFO ( http://www.ppifo.org.uk) is not grant aided.

Weak driving with strong coupling produces synchronisation or coherenceand narrow statistical variance on outcomes. Strong driving with weak coupling produces unsynchronisation or decoherence- and wide variance on outcomes.
The Pendulum" by Baker and Blackburn. Huygens 1665 saw clock pendulums synchronize hanging on the same wall. A classical example of the weak driving, strong coupling case.