2021_Book_TextbookOfPatientSafetyAndClin

17 Patient Safety in Internal Medicine
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Table 17.5 (continued)
Bias Description Example Corrective strategy
Premature closure To stop seeking other
information after reaching
a diagnostic conclusion
The radiologist did not see a
second fracture, after the first has
been identified
Review the case, seek
other opinions (e.g.,
radiology backup), and
consult objective
resources (e.g., an
orthopedic review that
might include mention of
a common concomitant
fracture)
Representativeness
bias
Extrapolation bias a
To make a diagnosis
considering only typical
manifestations of a
disease
To generalize experiences
and clinical trial results to
groups of patients in
whom intended actions
have not been properly
evaluated
The physician missed a diagnosis
of myocardial infarction
presenting with nausea and
vomiting
The physician ordered a CT scan
to exclude an acute coronary
syndrome in a patient with
previous coronary artery bypass
grafting (CABG)
a
These biases can affect not only diagnostic process but also treatment decisions
Consider atypical
manifestations, especially
in women
Use tests for evidencebased
indications
erroneous consideration of tests value, poor
supervision of N-AR [28]. At the end, also noisy
environment, interruptions, high workload,
fatigue, and time pressure can impair reasoning
[27].
Health Research & Educational Trust (HRET),
Hospital Improvement Innovation Network
(HIIN) team, and Society to Improve Diagnosis
in Medicine (SIDM) [29] published “Diagnostic
error—Change Package,” a document including a
menu of strategies and concepts that any hospital
should implement (improving teamwork effectiveness
and diagnostic process reliability, engaging
patients and caregivers, reinforcing learning
system, and optimizing cognitive performances
of clinicians) [29]. For this last aim, several tools
are available: (a) checklists for diagnostic process
such as CATCH (Comprehensive history
and physical exam, Alternate explanations, Take
a diagnostic timeout to be certain, Consider critical
diagnoses not be missed, Help if needed)
[30]; (b) mnemonic decision support tools like
VITAMIN CC & D checklist (Vascular, Infection
& Intoxication, Trauma & Toxins, Autoimmune,
Metabolic, Idiopathic & Iatrogenic, Neoplastic,
Congenital, Conversion, Degenerative); (c) lists
of Red Flags; (d) electronic decision support systems
like Isabel, associated with the highest
accurate diagnosis retrieval rates [31]; (e) debiasing
questions (Table 17.6) [32]; (f) reflective
practice by the following options:
––
The crystal ball experience [29]: stop and ask:
“if my diagnosis was wrong, which alternatives
should I consider?”
––
The ROWS (Rule Out Worst case Scenario)
[29]: exclude first the most severe possible
diagnoses.
––
The Blue and Red Team Challenge [33], borrowed
from military sector, is a safe method to
improve clinical decision-making in complex
clinical situations. Staff is divided into two
teams: the Blue Team takes clinical history,
makes the synthesis and generates diagnostic
hypotheses; the Red Team acts as an independent
reviewer by thinking critically about the
clinical picture and identifying alternative
diagnoses to those presented.
––
Take 2—think, do [32] is designed to improve
awareness and recognition of potential errors
and reduce morbidity and mortality of wrong,
missed, or delayed diagnosis. Literally, it
means “Take 2 minutes to deliberate diagnosis”
to verify if there are situations that need a
closer look or diagnosis re-evaluation (Think
moment) and act (Do moment). A closer look
is necessary if physician is Hungry, Angry,