SEGURIDAD CLINICA Y PRACTICA SEGURIDAD CLINICA Y PRACTICA

CLINICA REFLEXIVACLINICA REFLEXIVACLINICA REFLEXIVACLINICA REFLEXIVA

Francesc Borrell i Carrió.

Profesor Titular de MFC, Facultad Medicina, Universidad Barcelona, Departament de

Ciències Clíniques. EAP Gavarra. ICS

Email.- 12902fbc@comb.cat

CONTENIDOS

Introducción.-

Modelo centrado en el paciente. Self awareness.

El acto clínico.-

Lo que sabemos

-Estudios epidemiológicos.

-Estudios de performance, (Pacientes Incógnito).

Estrategias de mejora.

El profesional

El sistema.

-Prefaseg.

VALORES CLAVE DEL MODELO

• AFLORAR: necesidades, perspectiva y valores del paciente.

• COMPARTIR: decisiones, comprensión.• COMPARTIR: decisiones, comprensión.

• CONSTRUIR: una relación empática y

sensible (responsiveness).

MODELO CENTRADO EN EL PACIENTETAREAS EN LA ENTREVISTA.

• FASE EXPLORATORIA:

– El paciente puede hablar. Ocupación verbal.

– Más allá del síntoma aparece la persona:

• Creencias, ilusiones, expectativas, miedos…• Creencias, ilusiones, expectativas, miedos…

• FASE RESOLUTIVA:

– El paciente puede participar:

• En la definición de su problema.

• En el plan de actuación.

PRACTICA CLINICA REFLEXIVA.

• ME OBSERVO:– En el “ahora”, sin idealizarme, escuchando mis

emociones que me advierten de peligros.

• REFLEXION EN LA ACCION:– Escuchamos y exploramos para crearnos una imagen – Escuchamos y exploramos para crearnos una imagen

del paciente. Independencia de criterio.– Integro los datos en la persona:

• Terreno biológico, contexto psicosocial.

• REFLEXION FUERA DE LA CONSULTA:– Gestión poblacional. Prevención.– Gestión individual:

• Pongo al paciente en mi agenda.• Comparto con el equipo.

¿Aporta algo que no nos aporte el enfoque sistémico?

Acciones claras y muchas veces simples.Acciones claras y muchas veces simples.

Accountability.

Políticas organizacionales.

ESTUDIOS INTERNACIONALES

• Leape L, Brennan TA, Laird N, et al. The nature of adverse events in hospitalizedpatients: results of the Harvard Medical Practice Study II. N Engl J Med. 1991;324:377–384.

• Wilson RM, Harrison BT, Gibberd RW, Hamilton JD. An analysis of the causes of adverseevents from the Quality in Australian Health Care Study. Med J Aust. 1999;170:411–415.

• Bhasale A, Miller G, Reid S, Britt HC. Analyzing potential harm in Australian general practice: an incident-monitoring study. Med J Aust. 1998;169:73–76.practice: an incident-monitoring study. Med J Aust. 1998;169:73–76.

• Thomas EJ, Studdert DM, Burstin HR, et al. Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care. 2000;38:261–271.

• Baker GR, Norton PG, Flintoft V, et al. The Canadian Adverse Events Study: theincidence of adverse events among hospital patients in Canada. CMAJ. 2004;170:1678 –1686.

• Davis P, Lay-Yee R, Briant R, Ali W, Scott A, Schug S. Adverse events in New Zealandpublic hospitals II: preventability and clinical context. N Z Med J. 2003;116:U624.

ERROR MEDICO

• Toma de datos.

• Diagnósticos.

• Tratamiento.

• Seguimiento.

ENEAS 9,3% (525/5.624); IC95%: 8,6% - 10,1%INGRESOS• Medicación: 37,4% • Infecciones nosocomiales 25,3% • Problemas técnicos 25,0%• Diagnóstico 2,75%

APEAS 11,18‰ (IC95%: 10,52 - 11,85). CONSULTAS• Medicación: 48,2% • Seguimiento.• Medicación: 48,2% • Cuidados 25,7% • Comunicación 24,6% • Diagnóstico 13,1% • Gestión 8,9% • Otros 14,4%

IBEAS, (10,5% EA) OTROS.-

Jesús María Aranaz Andrés

TOTAL Moderados-graves

Eventosadversos relacionadosconlamedicación

47,7% 30,0%-5,7%

RAM evitables

59,1% 66,1%evitables

LO QUE NO PUEDE VER EL APEAS

• Errores en la comunicación y relación asistencial.

• Desacierto diagnóstico o falta de diagnóstico sin consecuencias inmediatas y diagnóstico sin consecuencias inmediatas y no percibido por informante.

• Omisión de maniobras diagnósticas, terapéuticas o preventivas.

• Falta de seguimiento.

INCLUSO CUANDO TENEMOS SISTEMA DE NOTIFICACION CONFIDENCIAL….

Muchos errores diagnósticos no se detectan como EA:

• “La mayor parte de errores diagnosticosprevenibles no se informan a través de los prevenibles no se informan a través de los medios de notificación voluntario”. Fischer G, Fetters

MD, Munro AP, Goldman EB. Adverse events in primary care identified from a risk-management database. J Fam Pract. 1997;45:40–46

• Ninguno de los errores de diagnóstico que revelaron los residentes había sido informado a las base de datos.

• Weingart S, Ship A, Aronson M. Confidential clinical-reported surveillance of

adverse events among medical inpatients. J Gen Intern Med. 2000;15:470–477.

“NEGACIONISMO”

• El 28% eran “negadores”(I.C95%: 22.34-34.26), • 67 % “perceptivos” (I.C95%: 60.79-73.23),• 7.4% “hiperperceptivos” (I.C95%: 4.41-11.44), • 6% “locus interno”(I.C95%: 3.34-9.91), • 23.4 % hiperseguros(I.C95%: 18.14-29.22).

• Se informó sobre 10.6 acontecimientos adversos/año/profesional, sobretodo eventos adversos de fármacos (37%)(I.C95%: 35.36-39.15) , y sobretodo eventos adversos de fármacos (37%)(I.C95%: 35.36-39.15) , y retraso diagnóstico en patología neoplásica (33%) (I.C95%: 31.16-34.85).

Berner ES, Graber ML Overconfidence as a Cause of Diagnostic Error in MedicineThe American Journal of Medicine (2008) Vol 121 (5A), S2–S23

Borrell F, Paez C, Suñol R, Orrego C, Gil N, Marti M Errores clínicos y eventos adversos: percepción de los médicos de atención primaria. Aten Primaria 2006; 38(1):25-32

Solo 1% admite públicamente haberse equivocado en el último año.

Graber ML. 5 años, 3 centros, 100 casos de error diagnóstico.

• *Sistémicos: fallos tecnológicos, mala organización. 65%

• *No error: falta colaboración paciente, presentación atípica 44%

• *Cognitivos: falta de conocimiento, toma de datos, sintesis de datos. 74%

• Dentro de los cognitivos:• Dentro de los cognitivos:

• Falta de conocimientos 11 ocasiones

• Falta de datos tomados del paciente: 45

• Falta de procesamiento adecuado de la información 159

• Falta de verificación 106

• CAUSA PROFUNDA: CIERRE PRECIPITADO

Graber ML, Franklin N, Gordon RR. Diagnostic error in internalmedicine. Arch Intern Med. 2005;165:1493–1499.

“Error diagnóstico”

• “Diagnostic error”: retraso no intencionado(existía suficiente información previa), equivocado(otro diagnóstico se realizó antes del correcto), o no presente (no se realizódel correcto), o no presente (no se realizódiagnóstico), desde la perspectiva de unainformación final mas definitiva.

Graber ML, Franklin N, Gordon RR. Diagnostic error in internalmedicine. Arch Intern Med. 2005;165:1493–1499.

Errores por especialidades

• -Especialidades perceptivas: radiologia 5%, A Patologica <5%, Dermatologia 11%.

• -Especialidades médicas 10-15%.

• -Superior en urgencias y entornos de alta • -Superior en urgencias y entornos de alta densidad de decisiones.

Berner ES, Graber ML Overconfidence as a Cause of Diagnostic Error in MedicineThe American Journal of Medicine (2008) Vol 121 (5A), S2–S23

Errores por patologias

Entidad % Cometarios

Aneurisma Aorta 35% Precordialgias, 1era evaluacion sin diag.

Hemorragia subaracn 30% 1era. evaluacion sin diagnóstico

Mamografia Ca mama 21% 1era. lectura con error

T. Bipolar 69% Diagnóstico inicial incorrecto

Artr. Psoriásica 39% 1era vista reumatólogo no diagn.

Diabetes Mellitus 18% No consta diagnóstico en HC

Lectura Radiografias 30% Errores cuando leídas en consulta (no radiólogo).

EL ENFOQUE SISTEMICO DEBE AFRONTAR UNA REALIDAD

INCOMODA

LA PERSONA ES PARTE DEL SISTEMA

EL MEDICO COMO CAJA NEGRA

datos DecisionesActos Actos

EL MEDICO COMO CAJA NEGRA

• FALIBILIDAD.

• MEJOR EFICIENCIA.

– Curva de rendimiento.

• MANTENIMIENTO• MANTENIMIENTO

• “OXIDACION”

¡SI AL MENOS SE NOS CONSIDERARA COMO UNA MÁQUINA!

¿COMO APROXIMARNOS A ESTA INCOMODA REALIDAD?

ESTUDIOS DE LABORATORIO

ESTUDIOS EN LAS CONDICIONES NATURALES DEL PROFESIONAL

ESTUDIOS NIVEL 4

PIRAMIDE DE MILLER

PACIENTE ESTANDARIZADO Y ENMASCARADO

PREPARACION VISITA CONPREPARACION

ENMASCARAMIENTO

SALA ESPERA

RECUPERACIONDE DATOS –ENCUESTA

VISITA CONAUDIOGRABACION

ESTUDIOS ESPAÑOLES• Suñol R: Correlación entre los procesos y los

resultados de la Entrevista Clínica: su aplicación a los programas de calidad en Atención Primaria. Tesis Doctoral, Universidad Autónoma de Barcelona. Barcelona, 1992

• Prados Castillejo, JA. Distorsión en las Técnicas Comunicacionales (Entrevista Clínica) en las Comunicacionales (Entrevista Clínica) en las consultas de Demanda de Atención Primaria. Tesis Doctoral. Universidad de Córdoba. Facultad de Medicina. Departamento de Medicina. Córdoba 1996 .

• Barragán N, Violan C, Martín Cantera C, Ferrer-Vidal D, González-Algas J. Diseño de un método para la evaluación de la competencia clínica en atención primaria Aten Primaria. 2000 Nov 30;26(9):590-4.

ESTUDIOS ESPAÑOLES

• Borrell F.,Fontova B, Muñoz E, Prados JA, Pedregal M, Peguero E. Physician´́́́s ability to find a physical sign (hepatomegaly). European Journal Gen Pract 2011.

• Llor C, Cots JM. The sale of antibioticswithout prescription in pharmacies in without prescription in pharmacies in Catalonia, Spain.Clin Infect Dis. 2009 May15;48(10):1345-9.

ESTUDIOS INTERNACIONALES

• 46 TRABAJOS, 24 EN LOS ÚLTIMOS 5 AÑOS.1.-McLeod PJ, et al. Use of standardized patients to assess between-physician variations in resource utilization JAMA. 1997 Oct 8;278(14):1164-8

2.-Dresselhaus TR, et al The ethical problem of false positives: a prospective evaluation of physician reporting in the medical record J Med Ethics. 2002 Oct;28(5):291-43.- Rethans jj, Sturmans F, Drop R, Van der Vleuten c, Hobus P. Does competence of general practitioners predict their performance? Comparison between examination setting and actual practices BMJ 1991 Nov 30;303(6814):13774.-.- Suñol R: Correlación entre los procesos y los resultados de la Entrevista Clínica: su aplicación a los programas de calidad en Atención Primaria. Tesis Doctoral, Universidad Autónoma de Barcelona. Barcelona, 19925.- Borrell F.,Fontova B, Muñoz E, Prados JA, Pedregal M, Peguero E. Physician ´́́́s ability to find a physical sign (hepatomegaly). European J Gen Pract 2011.6.-Franz CE, Epstein R, Miller KN, Brown A, Song J, Feldman M, Franks P, Kelly-Reif S, Kravitz RL. Caught in the act? Prevalence, predictors, and consequences of physician detection of unannounced standardized patients. Health Serv Res. 2006 Dec;41(6):27.-Gallagher TH, Lo B, Chesney M, Christensen K. How do physicians respond to patient's requests for costly, unindicated services?J Gen Intern Med. 1997 Nov;12(11):663-8.8.-Kravitz RL, Epstein RM, Feldman MD, Franz CE, Azari R, Wilkes MS, Hinton L, Franks P. Influence of patients' requests for direct-to-consumer advertised antidepressants: a randomized controlled trial.JAMA. 2005 Apr 27;293(16):1995-2002.9.-Brown JA, Abelson J, Woodward CA, Hutchison B, Norman G. Fielding standardized patients in primary care settings: lessons from a study using unannounced standardized patients to assess preventive care practices. Int J Qual Health Care. 1998 Jun;10(3)10.-Zabar S, Ark T, Gillespie C, Hsieh A, Kalet A, Kachur E, Manko J, Regan L. Can unannounced standardized patients assess professionalism and communication skills in the emergency department? Acad Emerg Med. 2009 Sep;16(9):91511.-Epstein RM, Levenkron JC, Frarey L, Thompson J, Anderson K, Franks P. Improving physicians' HIV risk-assessment skills using announced and unannounced standardized patients. J Gen Intern Med. 2001 Mar;16(3):17611.-Epstein RM, Levenkron JC, Frarey L, Thompson J, Anderson K, Franks P. Improving physicians' HIV risk-assessment skills using announced and unannounced standardized patients. J Gen Intern Med. 2001 Mar;16(3):17612.-Srinivasan M, Franks P, Meredith LS, Fiscella K, Epstein RM, Kravitz RL. Connoisseurs of care? Unannounced standardized patients' ratings of physicians. Med Care. 2006 Dec;44(12):1092-8.13.- Fiscella K, Franks P, Srinivasan M, Kravitz RL, Epstein R. Ratings of physician communication by real and standardized patients. Ann Fam Med. 2007 Mar-Apr;5(2):151-8.14.- Ozuah PO, Reznik M. Residents' asthma communication skills in announced versus unannounced standardized patient exercises.Ambul Pediatr. 2007 Nov-Dec;7(6):445-8.15.- Barragán N, Violan C, Martín Cantera C, Ferrer-Vidal D, González-Algas J. Diseño de un método para la evaluación de la competencia clínica en atención primaria Aten Primaria. 2000 Nov 30;26(9):590-4.16.- Prados Castillejo, JA. Distorsión en las Técnicas Comunicacionales (Entrevista Clínica) en las consultas de Demanda de Atención Primaria. Tesis Doctoral. Universidad de Córdoba. Facultad de Medicina. Departamento de Medicina. Córdoba 1996 17.-Krane NK, Anderson D, Lazarus CJ, Termini M, Bowdish B, Chauvin S, Fonseca V. Physician practice behavior and practice guidelines: using unannounced standardized patients to gather data.J Gen Intern Med. 2009 Jan;24(1):53-6. Epub 2008 Oct 31.18.- Feldman MD, Franks P, Duberstein PR, Vannoy S, Epstein R, Kravitz RL. Let's not talk about it: suicide inquiry in primary care.Ann Fam Med. 2007 Sep-Oct;5(5):412-8.19. Epstein RM, Shields CG, Meldrum SC, Fiscella K, Carroll J, Carney PA, Duberstein PR. Physicians' responses to patients' medically unexplained symptoms. Psychosom Med. 2006 Mar-Apr;68(2):269-76.20. Seaburn DB, Morse D, McDaniel SH, Beckman H, Silberman J, Epstein R. Physician responses to ambiguous patient symptoms.J Gen Intern Med. 2005 Jun;20(6):525-30.21.- Peabody JW, Luck J, Jain S, Bertenthal D, Glassman P. Assessing the accuracy of administrative data in health information systems.Med Care. 2004 Nov;42(11):1066-72.22. Carney PA, Dietrich AJ, Eliassen MS, Owen M, Badger LW. Recognizing and managing depression in primary care: a standardized patient study. J Fam Pract. 1999 Dec;48(12):965-72.23.-Kravitz RL, Franks P, Feldman M, Meredith LS, Hinton L, Franz C, Duberstein P, Epstein RM. What drives referral from primary care physicians to mental health specialists? A randomized trial using actors portraying depressive symptoms. J Gen Intern24.- Woodward CA, Hutchison B, Norman GR, Brown JA, Abelson J.What factors influence primary care physicians' charges for their services? An exploratory study using standardized patients. CMAJ. 1998 Jan 27;158(2):197-202.25.- Rethans JJ, Saebu L. Do general practitioners act consistently in real practice when they meet the same patient twice? Examination of intradoctor variation using standardised (simulated) patients. BMJ. 1997 Apr 19;314(7088):1170

RESUMEN DE ESTOS TRABAJOS

Fiabilidad, validez, detección o sospecha del paciente, factibilidad y

satisfacción del profesional.

ASPECTOS GENERALES

• PSI mejor método para analizar acto asistencial.

• Competencia y Performance son diferentes.

• Historia Clínica (notas clínicas) poco fiables para juzgar calidad.juzgar calidad.

• El Paciente Problema inhibe habilidades de anamnesis.

• Gran esfuerzo para gestionar el tiempo.

• Las expectativas del paciente marcan diferentes “finales”.

SITUEMOS ESTOS HALLAZGOS EN UN MODELO

Borrell-Carrió F. Epstein R Preventing errors in clinical practice: a call for self-awareness Ann Fam Med 2004;2(4):310-316.

¿COMO LLEGAMOS A UN DIAGNÓSTICO?

SITUACIÓN-ESTÍMULAR:INTENCIONALIDAD

PRIMERASHIPÒTESIS

CONDUCTASREENCUADRE

CONDUCTASVERIFICACIÓN

CONDICIONES DESUFICIENCIA

“OFERTA” QUE HAREMOS AL PACIENTE

COLAPSOCOGNITIVO

CAPACIDAD VERSUS DISPOSICION.

• CAPACIDAD: COMPETENCIA, NIVEL 3. “GENOTIPO”.

• DISPOSICIÓN: PERFORMANCE, NIVEL 4. “FENOTIPO”.“FENOTIPO”.

• CAPACIDAD :• PERCEPTIVA, • COGNITIVA, • CONDUCTUAL.

LO QUE SOY CAPAZ DE HACERAHORA Y AQUÍ

FACTORES RESTRICTIVOS

DISPOSICIONES AFECTIVAS, ACTITUDINALES/ CARACTERIALES Y COGNITIVAS.

• AFECTIVAS:

• ESTADOS TRANSITORIOS: cansancio, ruido, calor o frío, hiperestimulación sensorial, deprivación sueño, etc.

• SITUACION CLINICA: agresividad, contra- transferencia, atribuciones…atribuciones…

• SITUACION AFECTIVA ENDOGENA: trastorno del humor, de ansiedad, trastornos ciclotímicos, circadianos, etc.

Pat Croskerry, Allan A Abbass, Albert W Wu How doctors feel: aff ective issues in patients’ safetyThe Lancet Vol 372 October 4, 2008 1205-6

DISPOSICIONES AFECTIVAS, ACTITUDINALES/ CARACTERIALES Y COGNITIVAS.

• ACTITUDINALES / CARACTERIALES:• Rasgos polares que limitan o sesgan la percepción y o el razonamiento.-

• -Profesional frío, distante y “muy técnico” // hipersensible al sufrimiento ajeno, complaciente, busca “agradar”.

• -Profesional inseguro- reduccionista- evitador // hiperseguro, resolutivo.resolutivo.

• Rasgos que limitan o sesgan el razonamiento.-

• -Profesional altamente atributivo, culpabilizador, testarudo.

• -Profesional altamente defensivo, autoritario o paternalista

• -Profesional irónico- egodistónico- solipsista

• -Profesional «ansioso-asegurador», temeroso, obsesivo.

Borrell-Carrio F, Epstein RM, Pardell H.. Profesionalidad y professionalism: Fundamentos, contenidos, praxis y docencia

Med Clin (Barc). 2006;127(9):337-42

DISPOSICIONES AFECTIVAS, ACTITUDINALES/ CARACTERIALES Y COGNITIVAS.

• COGNITIVAS:

• *FALTA DE CONOCIMIENTOS/RECONOCIMIENTO

• *HEURISTICOS Y/O CRITERIOS ERRÓNEOS

• *RAZONAMIENTO

Desenfocado: • Desenfocado: Inadecuado para la situación.

• Intolera “no saber”: Precipita cierre entrevista.

• Pereza de reacción: Inercia diagnóstica.

• Baja productividad ideativa

• Confirmatorio:

• Dependencia de otros.

• Banaliza los síntomas/signos del paciente.

•

DISPOSICIONES COGNITIVAS (i) (Croskerry P, The Importance of Cognitive Errors in Diagnosis and Strategies to Minimize Them , Academic Medicine

2003; 78(8): 775-780)

• Aggregate bias: when physicians believe that aggregated data, such as those used to develop clinical practice guidelines, do not apply to individual patients (especially their own), they are invoking the aggregate fallacy. The belief that their patients are atypical or somehow exceptional may lead to errors of commission, e.g., ordering x-rays or other tests when guidelines indicate none are required.

• Anchoring: the tendency to perceptually lock onto salient features in the patient’s initial presentation too early in the diagnostic process, and failing to adjust this initial impression in the light of later information. This CDR may be severely compounded by the confirmation bias. Ascertainment bias: occurs when a physician’s thinking is shaped by prior expectation; stereotyping and gender bias are both good examples.

• Availability: the disposition to judge things as being more likely, or frequently occurring, if they readily come to mind. Thus, recent experience with a disease may inflate the likelihood of its being diagnosed. Conversely, if a disease has not been seen for a long time (is less available), it may be underdiagnosed.

• Base-rate neglect: the tendency to ignore the true prevalence of a disease, either inflating or reducing its base-rate, and distorting • Base-rate neglect: the tendency to ignore the true prevalence of a disease, either inflating or reducing its base-rate, and distorting Bayesian reasoning. However, in some cases, clinicians may (consciously or otherwise) deliberately inflate the likelihood of disease, such as in the strategy of ‘‘rule out worst-case scenario’’ to avoid missing a rare but significant diagnosis.

• Commission bias: results from the obligation toward beneficence, in that harm to the patient can only be prevented by active intervention. It is the tendency toward action rather than inaction. It is more likely in over-confident physicians. Commission bias is less common than omission bias.

• Confirmation bias: the tendency to look for confirming evidence to support a diagnosis rather than look for disconfirming evidence to refute it, despite the latter often being more persuasive and definitive.

• Diagnosis momentum: once diagnostic labels are attached to patients they tend to become stickier and stickier. Through intermediaries (patients, paramedics, nurses, physicians), what might have started as a possibility gathers increasing momentum until it becomes definite, and all other possibilities are excluded.

• Feedback sanction: a form of ignorance trap and time-delay trap CDR. Making a diagnostic error may carry no immediate consequences, as considerable time may elapse before the error is discovered, if ever, or poor system feedback processes prevent important information on decisions getting back to the decision maker. The particular CDR that failed the patient persists because of these temporal and systemic sanctions.

• Framing effect: how diagnosticians see things may be strongly influenced by the way in which the problem is framed, e.g., physicians’ perceptions of risk to the patient may be strongly influenced by whether the outcome is expressed in terms of the possibility that the patient might die or might live. In terms of diagnosis, physicians should be aware of how patients, nurses, and other physicians frame potential outcomes and contingencies of the clinical problem to them.

• Fundamental attribution error: the tendency to be judgmental and blame patients for their illnesses (dispositional causes) rather

than examine the circumstances (situational factors) that might have been responsible. In particular, psychiatric patients, minorities, and other marginalized groups tend to suffer from this CDR. Cultural differences exist in terms of the respective weights attributed to dispositional and situational causes.

• Gambler’s fallacy: attributed to gamblers, this fallacy is the belief that if a coin is tossed ten times and is heads each time, the 11th toss

has a greater chance of being tails (even though a fair coin has no memory). An example would be a physician who sees a series of patients with chest pain in clinic or the emergency department, diagnoses all of them with an acute coronary syndrome, and assumes the sequence will not continue. Thus, the pretest probability that a patient will have a particular diagnosis might be influenced by preceding but independent events.

• Gender bias: the tendency to believe that gender is a determining factor in the probability of diagnosis of a particular disease when no

such pathophysiological basis exists. Generally, it results in an overdiagnosis of the favored gender and underdiagnosis of the neglected gender.

• Hindsight bias: knowing the outcome may profoundly influence the perception of past events and prevent a realistic appraisal of what

DISPOSICIONES COGNITIVAS (ii)DISPOSICIONES COGNITIVAS (ii) (Croskerry P, The Importance of Cognitive Errors in Diagnosis and Strategies to Minimize Them , Academic Medicine

2003; 78(8): 775-780)

• Hindsight bias: knowing the outcome may profoundly influence the perception of past events and prevent a realistic appraisal of what

actually occurred. In the context of diagnostic error, it may compromise learning through either an underestimation (illusion of failure) or overestimation (illusion of control) of the decision maker’s abilities.

• Multiple alternatives bias: a multiplicity of options on a differential diagnosis may lead to significant conflict and uncertainty. The

process may be simplified by reverting to a smaller subset with which the physician is familiar but may result in inadequate consideration of other possibilities. One such strategy is the three-diagnosis differential: ‘‘It is probably A, but it might be B, or I don’t know (C).’’ Although this approach has some heuristic value, if the disease falls in the C category and is not pursued adequately, it will minimize the chances that some serious diagnoses can be made.

• Omission bias: the tendency toward inaction and rooted in the principle of nonmaleficence. In hindsight, events that have occurred

through the natural progression of a disease are more acceptable than those that may be attributed directly to the action of the physician. The bias may be sustained by the reinforcement often associated with not doing anything, but it may prove disastrous. Omission biases typically outnumber commission biases.

• Order effects: information transfer is a U-function: we tend to remember the beginning part (primacy effect) or the end

(recency effect). Primacy effect may be augmented by anchoring. In transitions of care, in which information transferred from patients, nurses, or other physicians is being evaluated, care should be taken to give due consideration to all information, regardless of the order in which it was presented.

• Outcome bias: the tendency to opt for diagnostic decisions that will lead to good outcomes, rather than those associated with bad

outcomes, thereby avoiding chagrin associated with the latter. It is a form of value bias in that physicians may express a stronger likelihood in their decision-making for what they hope will happen rather than for what they really believe might happen. This may result in serious

DISPOSICIONES COGNITIVAS(iii)

• Overconfidence bias: a universal tendency to believe we know more than we do. Overconfidence reflects a tendency to act on incomplete information, intuitions, or hunches. Too much faith is placed in opinion instead of carefully gathered evidence. The bias may be augmented by both anchoring and availability, and catastrophic outcomes may result when there is a prevailing commission bias.

• Playing the odds: (also known as frequency gambling) is the tendency in equivocal or ambiguous presentations to opt for a benign diagnosis on the basis that it is significantly more likely than a serious one. It may be compounded by the fact that the signs and symptoms of many common and benign diseases are mimicked by more serious and rare ones. The strategy may be unwitting or deliberate and is diametrically opposed to the rule out worst-case scenario strategy (see base-rate neglect).

• Posterior probability error : occurs when a physician’s estimate for the likelihood of disease is unduly influenced by what has gone on before for a particular patient. It is the opposite of the gambler’s fallacy in that the physician is gambling on the sequence continuing, e.g., if a patient presents to the office five times with a headache that is correctly diagnosed as migraine on each visit, it is the tendency to diagnose migraine on the sixth visit.Common things for most patients continue to be common, and the potential for a nonbenign headache

DISPOSICIONES COGNITIVAS (iii) (Croskerry P, The Importance of Cognitive Errors in Diagnosis and Strategies to Minimize Them , Academic Medicine

2003; 78(8): 775-780)

diagnose migraine on the sixth visit.Common things for most patients continue to be common, and the potential for a nonbenign headache being diagnosed is lowered through posterior probability.

• Premature closure: a powerful CDR accounting for a high proportion of missed diagnoses. It is the tendency to apply premature closure to the decisionmaking process, accepting a diagnosis before it has been fully verified. The consequences of the bias are reflected in the maxim: ‘‘When the diagnosis is made, the thinking stops.’’

• Psych-out error : psychiatric patients appear to be particularly vulnerable to the CDRs described in this list and to other errors in their management, some of which may exacerbate their condition. They appear especially vulnerable to fundamental attribution error. In particular, comorbid medical conditions may be overlooked or minimized. A variant of psych-out error occurs when serious medical conditions (e.g., hypoxia, delerium, metabolic abnormalities, CNS infections, head injury) are misdiagnosed as psychiatric conditions.

• Representativeness restraint: the representativeness heuristic drives the diagnostician toward looking for prototypical manifestations of disease: ‘‘If it looks like a duck, walks like a duck, quacks like a duck, then it is a duck.’’ Yet restraining decision-making along these pattern-recognition lines leads to atypical variants being missed.

• Search satisfying : reflects the universal tendency to call off a search once something is found. Comorbidities, second foreign bodies, other fractures, and coingestants in poisoning may all be missed. Also, if the search yields nothing, diagnosticians should satisfy themselves that they have been looking in the right place.

DISPOSICIONES COGNITIVAS(iv)

• Sutton’s slip: takes its name from the apocryphal story of the Brooklyn bank-robber Willie Sutton who, when asked by the Judge why he robbed banks, is alleged to have replied: ‘‘Because that’s where the money is!’’ The diagnostic strategy of going for the obvious is referred to as Sutton’s law. The slip occurs when possibilities other than the obvious are not given sufficient consideration.

• Sunk costs: the more clinicians invest in a particular diagnosis, the less likely they may be to release it and consider alternatives. This is an entrapment form of CDR more associated with investment and financial considerations. However, for the diagnostician, the investment is time and mental energy and, for some, ego may be a precious investment. Confirmation bias may be a manifestation of such an unwillingness to let go of a failing diagnosis.

• Triage cueing : the triage process occurs throughout the health care system, from the self-triage of patients to the selection of a specialist by the referring physician. In the emergency department, triage is a formal process that results in patients being sent in particular directions, which cues their subsequent management. Many CDRs are initiated at triage, leading to the maxim: ‘‘Geography is destiny.’’

• Unpacking principle : failure to elicit all relevant information (unpacking) in establishing a differential diagnosis may result in significant

DISPOSICIONES COGNITIVAS (iv) (Croskerry P, The Importance of Cognitive Errors in Diagnosis and Strategies to Minimize Them , Academic Medicine

2003; 78(8): 775-780)

• Unpacking principle : failure to elicit all relevant information (unpacking) in establishing a differential diagnosis may result in significant possibilities being missed. The more specific a description of an illness that is received, the more likely the event is judged to exist. If patients are allowed to limit their history-giving, or physicians otherwise limit their history-taking, unspecified possibilities may be discounted.

• Vertical line failure: routine, repetitive tasks often lead to thinking in silos—predictable, orthodox styles that emphasize economy, efficacy, and utility. Though often rewarded, the approach carries the inherent penalty of inflexibility. In contrast, lateral thinking styles create opportunities for diagnosing the unexpected, rare, or esoteric. An effective lateral thinking strategy is simply to pose the question: ‘‘What else might this be?’’

• Visceral bias : the influence of affective sources of error on decision-making has been widely underestimated. Visceral arousal leads to poor decisions.

• Countertransference, both negative and positive feelings toward patients, may result in diagnoses being missed. Some attribution phenomena (fundamental attribution error) may have their origin in countertransference.

• Yin-Yang out : when patients have been subjected to exhaustive and unavailing diagnostic investigations, they are said to have been worked up the Yin-Yang. The Yin-Yang out is the tendency to believe that nothing further can be done to throw light on the dark place where, and if, any definitive diagnosis resides for the patient, i.e., the physician is let out of further diagnostic effort. This may prove ultimately to be true, but to adopt the strategy at the outset is fraught with the chance of a variety of errors.

ESTRATEGIAS DE MEJORA

• EL PROFESIONAL

• EL SISTEMA

ESTRATEGIAS DE MEJORA: EL PROFESIONAL.

• FORMAR– Patrones de reconocimiento de trastornos/

enfermedades y sus complicaciones.

– Script de los trastornos/enfermedades.

– Situaciones de alarma.

• COMPARTIR– Experiencias clínicas.

– Asesoramiento/tutorización directa.

• DAR FEEDBACK

Propósito Asunción Insuficiencias Enfoque

FORMACIONMetacognición Hábitos Conductas

mas complejas

Caro Individuo

Experteza Conocimientos Reconocer Caro Individuo

COMPARTIREn línea Validar

Sugerir otrosDiagn.

Amplia opciones No inmediato Individuo

Segunda opinión Idem Compartir criterios Solo casos “especiales”

Equipo

Sistema experto Sugerir Exhaustividad Solo casos “especiales”

Individuo

Participaciónpacientepaciente

FEEDBACKAutopsias Mejorar experiencia clínica Relacionar síntomas y

signos con diag no obvios

Caro, solo casos “especiales”, resistencia familiares

Equipo

Audit Mejorar procedimientos Disciplina trabajo conlleva mejores resultados

Nexo no bien establecido

Individuo / Equipo

Seguimiento Rectificar Ganar en flexibilidad;Evitar error o disminuir efectos.

Exige planificar. Individuo / Equipo

ESTRATEGIAS DE MEJORA: EL SISTEMA.

• MEJORAR EL RESCATE DE INFORMACION.

• MEJORAR LA COMUNICACIÓN ENTRE PROFESIONALES Y EL ACCESO A PRUEBAS.

• SISTEMAS EXPERTOS• SISTEMAS EXPERTOS

• ALERTAS

• TAREAS PENDIENTES

• GESTION DE POBLACIONES A RIESGO

HISTORIA CLÍNICA ELECTRÓNICA

• TAPIZ– LISTA PROBLEMAS– CURSO CLÍNICO

• PROBLEMAS/EPISODIOS

– PRESCRIPCIONES– PRESCRIPCIONES– HOJA MONITORIZACIÓN, HISTORICO DE PRUEBAS…

• INTERCONECTIVIDAD– PRUEBAS COMPLEMENTARIAS– HISTORIA CLINICA ELECTRONICA– CURSOS CLÍNICOS OTROS PROFESIONALES.

ALERTAS

• ANALITICAS /RADIOLOGIA

• ALTAS HOSPITALARIAS/URGENCIAS

• INTERCONSULTAS ESPECIALISTAS

• DEFUNCIONES

EN EL MOMENTODE LA CONEXION

• PREASEG

• TAREAS PENDIENTES

DURANTE EL ACTO CLÍNICO

PERFIL PRESCRIPCION

• ON TIME (PREFASEG):– INTERACCIONES.– REDUNDANCIAS (DUPLICADOS)– EDADES EXTREMAS– ENFERMEDADES/CONDICIONES DEL PACIENTE– REACCIONES ADVERSAS /ALERGIAS– REACCIONES ADVERSAS /ALERGIAS– TUTOR PEDIATRIA

• OFF TIME (SELF AUDIT):– REDUNDANCIAS (DUPLICADOS).– MAS DE 10 FÀRMACOS– NO RECOMENDADOS POR EDAD/ PROTECCIÓN

GÀSTRICA, ETC.

GESTION DE POBLACIONES A RIESGO

• OFF TIME– EPOC.– DIABETICOS– RIESGO CARDIOVASCULAR– OTROS…

• EN UN FUTURO• EN UN FUTURO– POBLACION DE ESPECIAL SEGUIMIENTO:

• DEFINIDO POR VARIOS FACTORES• DEFINIDO POR EL PROFESIONAL

– POBLACION DETECTADA POR SISTEMAS EXPERTOS.• VARIABLES BIOLOGICAS• VARIABLES PSICOSOCIALES

Prescripción Farmacológica SeguraPREFASEG

� Ester Amado

� Jose Miguel Baena

� Gladys Bendahan

� Arantxa Catalán� Leonardo Galván� Vicente Morales� Míriam Oms

Autores: CAMFiC i ICS

� Gladys Bendahan

� Francesc Borrell� Míriam Oms� Àngels Pons

Financiación: Aliança per la Seguretat dels Pacients (Departament de Salut, 2007)

Ministerio de Sanidad y Política Social (Seguridad de pacientes, 2009)

Con la colaboración de:

� Fundació Avedis Donabedian

� Subdirecció General de Recursos Sanitaris

PARA SABER MAS

• Aranaz JM, Aibar C, Vitaller J, Mira JJ Gestión Sanitaria. Calidad y Seguridad de los pacientes. Fundación MAPFRE. Diaz de Santos, Madrid 2008.

• Baron J. Thinking and Deciding. 3rd ed. Cambridge, UK:• Cambridge University Press; 2003.• Gigerenzer G. Simple Heuristics that Make Us Smart. Oxford, UK:

Oxford University Press; 1999.• Gigerenzer G. Simple Heuristics that Make Us Smart. Oxford, UK:

Oxford University Press; 1999.• Kassirer JP, Kopelman RI. Learning Clinical Reasoning.• Baltimore, MD: Williams & Wilkins; 1991.• Godoy A. Toma de decisiones y juicio clínico. Piramide. Madrid

1996.• Dowie JU, Elstein A. Professional judgement. A reader in clinical

decision making. Cambridge University Press. New York 1988

PARA SABER MAS

• Society of Medical Decision Making (available at: http://www.smdm.org

•• The Brunswik Society (available at: http://www.brunswik.org )

• Decision Analysis Society (available at: http://faculty.fuqua.duke.edu/daweb )

• Society for Judgment and Decision Making (available at: http://www.sjdm.org)• Society for Judgment and Decision Making (available at: http://www.sjdm.org)

• Center for Adaptive Behavior and Cognition (available at:

• http://www.mpib-berlin.mpg.de/en/research/adaptive-behavior-and-cognition

• AHRQ Web M&M, October 2007. Available at: http://www.webmm.ahrq.gov/index.aspx

MUCHAS GRACIAS POR VUESTRA ATENCION

NOS VEMOS EN:NOS VEMOS EN:

www.humedicas.blogspot.com

www.seguridadclinica.blogspot.com