For many years, the Canadian Medical Protective Association has been offering an education session in conjunction with its Annual Meeting. While previously held in different parts of the country, for the past two years the Annual Meeting and education session have been delivered virtually due to restrictions brought about by the COVID-19 pandemic. The result has been a resounding success. This year’s education session, held on August 16^th, was attended by 690 people, nearly three times the number of attendees the CMPA would normally see at an in-person event.

“We are so thrilled that members across the country, particularly in remote areas, now have access to our educational content,” said Dr. Lisa Calder, the CMPA’s Chief Executive Officer. “Our goal is to help reduce risk, and increase patient safety. There’s no better way to do that than to ensure physicians are equipped with the information and tools they need.”

The session featured real-time polling and a question-and-answer period with the expert panel comprising CMPA physician advisors and legal counsel. Making the session accessible to doctors from coast-to-coast-to-coast improved the reach of the CMPA’s risk management messages, especially important at a time when virtual diagnostic assessments have become a routine part of clinical practice owing to the pandemic.

2021 session highlighted interventions for safer diagnoses

The 2021 education session focused on an area of healthcare known to contribute significantly to patient safety issues and medico-legal cases: timely and accurate diagnoses. Participants reviewed the many challenges of diagnostic decision-making, and learned strategies to overcome them through illustrative case scenarios in three clinical contexts—virtual, acute, and post-op care.

Diagnostic error encompasses missed, wrong or delayed diagnoses. Any of these unintentional events can harm patients and potentially result in medico-legal difficulties for the physicians involved. Twenty-one percent of civil legal actions and College and hospital complaints in Canada feature diagnostic errors. This points to opportunities for care teams to improve their processes and approaches in this key area.

What the CMPA’s data reveals

Most diagnostic errors involve common health conditions such as cancers, injuries, infections, ischemic heart disease and stroke. Errors in judgment or reasoning account for a significant proportion of diagnostic errors. These cognitive factors can rarely be attributed to a health provider’s lack of knowledge. Rather, deficient information gathering and synthesis is most often at the root of the problem.

“Physicians strive to make the correct diagnosis while frequently contending with numerous complicating factors,” said Dr. Calder. “Having a structured approach to collecting and evaluating information is crucial to arriving at the right diagnosis.”

Strategies to reduce diagnostic errors

The session panelists suggested care teams use a multi-pronged approach aimed at supporting diagnostic reasoning:

• Look for information gaps during clinical assessment of a patient to help confirm the working diagnosis and rule out other, potentially more serious diagnoses.
• Formulate a reasonable differential diagnosis.
• Document in the medical record the pertinent findings from the clinical assessment, including how information was obtained during virtual assessments.
• Recognize “red flag” scenarios, such as repeated presentations with unresolved complaint or unexplained changes in physical signs such as vitals. Use them as triggers to slow down and focus attention on where it is needed most.
• Proactively seek additional information such as reading the notes of nurses and allied health professionals.
• Take a diagnostic pause by asking oneself, “does this make sense?,” “is the patient’s condition following a usual trend?”, or “what else could be going on?”.
• Plan for contingencies by asking “what if” questions (e.g. “what if the vitals change, what’s my plan if…?”).
• Close the loop on tasks by clarifying what needs to be done, when, and by whom.
• Optimize handovers of care by minimizing distractions and interruptions and using structured communication tools to exchange information and validate comprehension.
• Create a work environment where people feel safe to raise concerns and speak up when needed.
• Don’t forget about existing activities in the workplace (e.g. huddles, briefings, team meetings) to create shared mental models and opportunities for team members to practise speaking up.

Virtual diagnostic assessments

With the adoption of virtual care in many practice settings, no discussion about diagnostic approaches would be complete without also considering the choice between conducting virtual and in-person assessments. The general expectation is that physicians are to meet the standard of care, regardless of whether the care is delivered virtually or in person. Physicians should be mindful of the limitations of virtual care and ensure patients are provided the opportunity for in-person care, where appropriate and available. In addition, they are encouraged to be aware of the applicable guidance from their Colleges, specialty organizations, medical associations and federations, and to consult up-to-date resources such as the Canadian Medical Association’s Virtual Care Playbook.

View the education session online

The webcast, which features key learnings applicable to all types of practice, will be available on-demand via the CMPA website  by mid-September. As Dr. Calder sums up, “Interventions that enhance cognitive reasoning processes help members of the care team to be more aware of what’s going on around them and this also improves team communication. This is key to reducing the risk of patient harm related to clinical care.”

This article was submitted by The Canadian Medical Protective Association (CMPA).