MALPRACTICE IN MEDICAL DIAGNOSIS.pptx

Dr. MOSTAFA AL-WAKIL
M.D.,Ph.D.
Dr. mostafa al wakil

deviation of the doctor or medical
professional from a generally
accepted standard of care That
may cause harm to the patient or
loss.

 And patients are increasingly backed by favorable legal developments. .
Another major contributing factor is the substantial increase in costs of
health care.

There was time when doctors were given
a ‗GODLIKE‘ status and were held in the
highest esteem; and patients were intended
to be, well patient; passive and submissive.
But this has changed and Doctors are no
longer regarded as infallible and beyond
questioning
ALL

 ONE IN FIVE MEDICAL ERRORS ARE POTENIALLY
SERIOUS OR FATAL
 Source: ncbi.nim.nih.gov

Most common reasons for medical
malpractice claims
34% -surgery errors
46% -diagnostic errors

 Johns Hopkins researchers reported
Findings
 Diagnosis errors account for 160,000
deaths annually in the USA
 Source: National Center for Policy Analysis

 About 195,000 patients in the U.S. die from
preventable Misdiagnosis accounts for an
estimated errors in-hospitals each year
 David Newman-Toker, M.D., Ph.D.

 28%of 583 diagnostic mistakes reported
anonymously by doctors were life-
threatening or had resulted in death or
permanent disability

Egypt
In a study made
in 2015 in Dakhalia and Damietta Governorates: A 10
Year Evaluation The number of claims over the 10
years period was 1355 claims. there are significant
increases in reporting the medical error in private and
central hospitals than university hospitals
Distribution of Total Medical Claims
According to the Type of Hospital

What is Diagnosis ?
Diagnosis is The identification by a medical provider of a condition, disease,
or injury made by evaluating the symptoms and signs presented by a patient.
Diagnostic errors can lead to patient harm from wrong or delayed
testing or treatment.
For example
Globally, misdiagnoses may contribute to the nearly 7 million children who die
each year, mainly from preventable causes
Misdiagnosis (erroneous diagnosis)
Definition of misdiagnosis
It is the failure to (a) establish an accurate and timely
explanation of the patient’s health problem(s)
or (b) communicate that explanation to the patient

Why I must do mistakes ?

A cognitive system is a one that performs the cognitive work of knowing,
understanding, planning, deciding, problem solving, analyzing,
synthesizing, assessing, and judging as they are fully integrated with
perceiving and acting. and is consisting of two systems
System 1 and System 2 are two distinct modes of decision making: System 1 is an
automatic, fast and often unconscious way of thinking. It is autonomous and
efficient, requiring little energy or attention, but is prone to biases and systematic
errors. System 2 is an effortful, slow and controlled way of thinking
Inmedicine, most of our errors occur whilst in the intuitive (system 1)
mode of thinking…..
System 2
System 1 Dr. mostafa al wakil

Misdiagnosis has three major categories :
1-False positive : misdiagnosis of a disease that is not actually present
2-False negative : failure to diagnose a disease that is present
3-Equivocal results : inconclusive interpretations without a definite diagnosis
Overdiagnosis also has been described as “when a condition is
diagnosed that would otherwise not go on to cause symptoms or death”
(Welch and Black, 2010, p. 605).
it can lead to treatment that may cause harm.

1-Lack of sufficient, competent health care
professionals, for example, due to lack of training.
2-Poor teamwork, lack of learning and feedback when
errors occur.
3-Limited follow-up reduces the ability for diagnostic
impressions to evolve. Lack of follow up may lead to misdiagnosis as
some diseases start with symptoms or signs and after certain period may give
another symptoms or signs or even different picture even complications of
diseases or surgery or some procedures appears later
4-Human factors and cognitive issues
The work environment and systems may be
subject to distractions, interruptions and a lack of
organization of information.
5-Too much attention to one finding during the
examination
6-Influenced by similar case ( WHO 2016 )
causes of misdiagnosis

13,000 known diseases, syndromes, injuries
4,000 possible tests
6,000 medications, treatments, and surgeries
Complexity
in Medicine
The average limits of
human working memory:
7 discrete items

At-risk categories of harmful diagnostic errors
Infections
Viral infections Often misdiagnosed as bacterial and result in unnecessary
antibiotics
Cardiovascular disease
Myocardial infarction, stroke
Subtle premonitory symptoms at first-contact settings often missed
Delays in diagnosis prevalent in predisposing conditions, including type 2
diabetes (median delay >2 years; 7% remained undiagnosed at 7.5 years)
and hypertension
Cancer
Several cancer types
Alarm symptoms often poorly predictive low signal-to-noise ratio. Cancer
can be in differential of many common symptoms including headache, weight
loss, bleeding, pain
Pediatrics
suggests meningitis, gastroenteritis, pneumonia, appendicitis, sepsis and malignancy
Meningococcal disease
Misdiagnoses may contribute to the nearly 7 million children who die each
year, largely from preventable causes
viral infections diagnosed as bacterial infections, appendicitis ,hypertension and psychiatric
disorders

Outcomes
They are considered as missed opportunities to make a correct or timely
diagnosis based on available evidence. The missed opportunity may
result from cognitive or system factors or both. To reduce hindsight bias,
there should be evidence of omission (failure to do the right thing) or
commission (doing something wrong) at the point in time at which the
error occurred (5,6). Figure 1 depicts the relationship between diagnostic
errors, missed opportunities and patient harm. Opportunities could be
missed by providers, care teams, systems or the patient.
Figure 1. Conceptual model of missed opportunities in diagnosis

History is the most important part of diagnosis.
Omission of certain points in the history can lead to a
confusing clinical situation and unnecessary
investigations.
 It is told that the chief complaints are to be written
in the words of the patient. But always it will not be
possible. In fact in most of the situations it is not
possible. Our patients complain in their local
language not in scientific words. At times it becomes
difficult to understand their complaint even in the
local language. So physician should first try to
understand the complaint clearly and then convert it
into a scientifically meaningful word without altering
the meaning

A careful physical exam can help a clinician
refine the next steps in the diagnostic
process, can prevent unnecessary diagnostic
testing, and can aid in building trust with
the patient.
Healthcare providers have a duty to provide
information in simple, clear, and plain language and
to check that patients have understood the
information before ending the conversation

V ascular
I nfections & intoxications
T rauma & toxins
A uto-immune
M etabolic
I diopathic & iatrogenic
N eoplastic
C ongenital
C onversion (psychiatric)
D egenerative
Use mnemonics and tricks:

postmortem exams play a critical role in
understanding the epidemiology of diagnostic
errors
Teamwork in the diagnostic process involves the
collaboration of patients and their families; diagnosticians,
such as physicians, physician assistants
(PAs), and advanced practice nurses (APNs);
and health care professionals who support the diagnostic
process, such as nurses, pharmacists, laboratory
scientists, radiology technologists, medical assistants, and
patient navigators

Medical imaging is characterized not just by
the increasingly precise anatomic detail it
offers but also by an increasing capacity to
illuminate biology.
Lab investigations and imaging
Diagnostic Test and Screening Test
A diagnostic testis used to determine the presence or absence of a
disease when a subject shows signs or symptoms of the disease
A screening test identifies asymptomatic individuals who may
have the disease
The diagnostic test is performed after positive screening test to
establish a definitive diagnosis

diagnostic endoscopies
An endoscopy (looking inside) is used in medicine to look inside
the body. The endoscopy procedure uses an endoscope to
examine the interior of a hollow organ or cavity of the body.
Unlike many other medical imaging techniques, endoscopes are
inserted directly into the organ. it is used to diagnose , and treat
, usually it gives a confirmatory diagnosis in case of highly
suspicious diseases Dr. mostafa al wakil

A patient saw a family NP for a complaint of discharge and constant scabbing
of one of her nipples, of several months duration. The NP ordered topical
and oral antibiotics and a mammogram, which was negative. The patient
return seven months later with continuation of pain and discharge from the
same nipple. The NP referred the patient to a dermatologist. The patient
did not see the dermatologist. Four months later, the patient saw her
gynecologist, who again treated her breast symptoms with antibiotics, and
assured her that she did not have cancer. The patient saw the NP several
more times the year following the first visit. Eighteen months after the first
visit, the patient came to the NP with unmistakable masses in her breast.
The NP referred the patient to a surgical oncologist who diagnosed Paget’s
disease. The cancer had metastasized and the patient died shortly after the
diagnosis. The court said all three providers breached the standard of care.
Q. What the NP can learn from this case?
A. Always follow up on symptoms from the past.

 A 35-year-old woman visited a primary care physician’s office for various ailments in
2001 and 2002. She saw a primary care physician twice and a NP four times. The
patient had a history of spleenectomy in 1985. She had received a pneumovax
following the procedure. She not receive Haemophilus or meningococcal vaccine.
Subsequent to 2002 the patient developed a pneumococcal infection which called
for a 3-month hospitalization and a 2-month stay in a rehab facility. During her
hospitalization she became septic, suffered organ failure, and necrosis of her toes.
She can now walk only short distances and suffered from chronic infections and
pain. The patient/plaintiff contended that the standard of care required the
defendants to revaccinate the patient with a pneumovax booster due to her
asplenia. The plaintiff contended that if the defendants had complied with the
accepted standard of care, then she would have avoided her subsequent
pneumococcal infection. The clinicians argued that the patient’s visits had all been
for acute sick visits, not annual preventive and wellness physicians, which did not
provide them with the opportunity to recommend or administer a pneumococcal
vaccination. The parties reached a $3M settlement.
Q. What the NP can learn from this case?
A. Always perform a health-maintenance screen after every visit.

Use direct quotes to
demonstrate your attention
to the patient, highlight
main areas of concern, build
credibility into the record,
and accurately document a
patient’s competency,
affect, and attitude. For
example: “I have been to
12 doctors and no one can
help me”.

1. Be careful about establishing patient-
provider relationships. Giving medical
advice?exercise caution and use
reasonably ordinary care
2. Know the standard of care and practice
within it
3. Follow your practice guidelines
4. If in doubt use the conservative approach
5. Rule out the worst diagnoses early on
6. Know the limits of training and expertise
7. Follow up

‘Good doctors are not
those who don’t make
mistakes; good doctors
are those who expect to
make mistakes and act on
that expectation.’
James Reason

Malpractice litigation is said to target “bad” physicians and to be a
necessary
adjunct to regulatory and professional discipline (11), yet nearly
one in five doctors reports a malpractice claim annually and one-
third to
one-half of high-risk specialists face a claim every year. Are they all
bad
doctors?
Ref
11. Nace BJ, Stewart LS. Straight talk on medical malpractice.
American Trial Lawyers
Association, 1994:20.
12. Harming Patient Access to Care: Implications of Excessive
Litigation. Subcommittee
on Health, Committee on Energy and Commerce, US House of
Representatives.
Washington, DC: U.S. Government Printing Office, 2002:160.

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