Safe DiagnosisToward 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 OrganisationReducing 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

BackgroundLethal 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): 1235–1236 )• 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

Musculoskeletal

Lungs

Cardio

BloodLymphMarrow

Digestion

Urogenital

Endocrine

NervousBreast

Skin

Mucosa

Hair

Nails

Ear Eye

Body

The Nomencleture of Disease HMSO 8th edition

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 it’s 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;55:499–502

“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

-

50,000

100,000

150,000

200,000

250,000

300,000

1 2 3 4 5 6 7 8 9 10

Number of Independent Diagnoses

Errors per million

diagnoses

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

11049158617244697753,9064

15,6253

62,5002

250,0001

Errors per millionNo of Doctors

Assume no medical break throughs

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

0

50,000

100,000

150,000

200,000

250,000

300,000

1 2 3 4 5 6 7 8 9 10

75% error

80%

90%

95%

110

149

3158

13617

1642446110320977561001,6003,90641251,0008,00015,62532,50010,00040,00062,500250,000100,000200,000250,0001

95% error

90% error

80% error

75% error

Errors per millionDiagnostic Agreement

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

Audit

Operation

Regulation

Process

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 non-compliance 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.

“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.

Weak driving with strong coupling produces synchronisation or coherence- and narrow statistical variance on outcomes.

Strong driving with weak coupling produces unsynchronisation or decoherence- and wide variance on outcomes.