Why did I miss the diagnosis?

Dr Bhupendra Shah

Type of miss diagnosis

Misdiagnosis

Missed diagnosis

Delay in diagnosis

Why should we are discussing ? Prevalent

consequential

Similarities and contrast……

73 year /female abdominal distension-10 days dry cough- 10 days USG-Ascites with mesenteric lymphadenopathyXray- Left pleural effusionDiagnosis: disseminated Tuberculosis

abdominal distension persistent and appetite decreasingpresented with altered sensoriumserum Na -110 mg/dlhyponatremia treated and sensorium improvedDx—hyponatremia due to poor intake

What happen next?

Patient deteriote

Pleural effusion –progressive increasing

Pleural fluid cytology…metastasis (adenocarcinoma)

My patient suffer..who is resposnsible?

Why ???

History incomplete……

Physical examination not complete

Not analysed

Excessive reliance on lab report

Hyponatremia cause ….not analysed

65 year /male Loose motion -2 years Visited MOPD 4 times Given antibiotic No releived Colonoscopy planned …patient lost

follow up for 8-9 months with no releived of symptoms

Visited another doctor Diagnosis made..treated

26 year /male Fever -5 days , vomitting- 2 days Urine analysis-pyuria Dx-UTI discharge on antibiotics No releive of symptoms and visited other

hospital Dx –UTI with GERD Altered sensorium-1 days CT scan- frontotemporal enhancement

with diffuse brain edema

$1,600,000 settlement in a medical malpractice case involving the failure to take an adequate biopsy of a patients ulcer and thereby failure to diagnose gastric cancer.

$90,939,857 jury verdict for a child whose cerebral palsy was due to the failure of an obstetrician to diagnose placental abruption and who thus delayed the cesarean section that was necessary to rescue the baby who was suffering from a lack of oxygen.

$8,000,000 settlement for a woman in case in which doctors and hospital employees failed to timely diagnose a valvulus (twisting of the intestine) in a woman which cased multiple surgeries and hospitalizations and the need for an intestinal transplant.

MONDAY, April 22 (HealthDay News) :

Missed or wrong diagnoses made up the lion's share of U.S. malpractice payouts -- which totaled nearly $39 billion -- during the past 25 years, finds a new study of more than 350,000 claims.

अस्पतालमा तोडफोड ।

What went wrong??? And why?

Why did you miss the diagnosis It never crossed my mind.

Too much attention to one finding

Too much in hurry

Didn’t re-asses the situation

Influenced by similar case

Let the consultant convince me

Errors

Faulty detection

Faulty triggering of hypothesis

Most powerful diagnostic tool History

Examination skill

Reasoning abilities

Data gathering errors Incomplete history

Ineffective questioning

Faulty detection

Failure to screen

Overreliance on someone else’s history

Faulty physical examination technique

Data integration

Failure to consider finding

Faulty estimate of prevalence

Faulty context formulation

Overreliance on someone else’s opinion

Over or underestimation of finding

Situational errors Stress

Fatigue

Excessive workload

Physician mood and personality

Work environment :equipment ,support ,rewards and punishment.

Error in physical examination Technique

Omission

Detection

Intrepetation

recording

What to do now?????/

Analytical thinking

If you don’t know what to see ,you won’t see no matter how throughly you look for it.

Is it possible?

Self recognition

Assuming responsibility

Sharing emotions

Encourging people to share their thinking

Hello…………

Everyone makes mistake..no matter how confident anyone are in their abilities ,they are human.

Unfortunately …….

This is doesn’t apply to doctor…..

What next?

To ask

Why I miss the diagnosis?

Why you miss the diagnosis?

Why we miss the diagnosis?

references

Bordage G. Why did I miss the diagnosis? Some cognitive explanations and educational implications. Acad Med 1999;74:S138-S143.

Judith L. Bowen.Educational Strategies to Promote Clinical diagnostic Reasoning .N Engl J Med 2006;355:2217-25.

Thank you

Sir for motivating me to present this topic.

All for your participation