Key to preventing medical errors includes keeping an open mind

March 24, 2015

Dermatologists should refrain from developing an initial clinical impression and consider alternative diagnoses when seeing patients, an expert tells colleagues at the 73rd annual meeting of the American Academy of Dermatology.

Dermatologists may need to “take a step back” and not routinely make a diagnosis based on their initial clinical impression, says a professor of dermatology and director of residency and dermatopathology fellowship at Thomas Jefferson University, Jefferson University Hospitals, Philadelphia, Penn., speaking here at the 73rd annual meeting of the American Academy of Dermatology at a symposium on errors in diagnosis and patient safety.

“If you are not thinking of the diagnosis, you won’t be asking patients the appropriate questions,” according to Jason B. Lee, M.D.  “You have to step back and think about alternative diagnoses.  All of this is predicated on experience,” Dr. Lee says. “I tell residents the most important thing is seeing as many patients as possible and gaining experience. That will give you the tools to diagnose and treat these patients.”

It is important not to develop an “anchoring bias” based on initial information that is received, Dr. Lee says. Such a bias may mean clinicians adhere to an initial clinical impression and exclude the value of subsequent information that would have them entertain another diagnosis, Dr. Lee says. Such a bias might also see clinicians not ordering tests to rule out other possible diagnoses or pursue other possible diagnoses, Dr. Lee says.

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Incorrect diagnosis fuels inefficiency in healthcare because inappropriate therapy is typically prescribed and leaves patients insufficiently treated: An example may be an incorrect diagnosis of drug eruption, the prescription of prednisone, and the patient’s absence of response to treatment.

“The patient would get all the side effects of prednisone, a therapy that the patient did not need,”  Dr. Lee says.

Some errors in diagnosis in dermatology can be catastrophic: For instance, if a melanoma is missed or if toxic epidermal necrolysis is not diagnosed, but those conditions are top of mind for dermatologists and are largely correctly diagnosed, Dr. Lee says.

Incorrect diagnoses can appear in a patient’s medical chart despite the existence of electronic medical records, Dr. Lee says.  In addition, there are also “no fault” errors in diagnosis where patients are communicating inaccurate information to a dermatologist or deliberately lying, Dr. Lee says. Very rare cases present a challenge of correct diagnosis for many dermatologists, Dr. Lee says.

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Dermatologists may be affected by factors like fatigue, which can lead to diagnostic errors, Dr. Lee says.  “Physical state such as being tired or overworked or having stresses in life can affect your ability to make diagnoses,” Dr. Lee says. “Well-being is important in any decision-making (process).”

If challenged by a case, clinicians may consider referring a patient to a colleague to get “fresh eyes” on a case, Dr. Lee says.