A quality assurance committee is conducting an assessment of diagnostic errors related to myocardial infarction (MI) in the emergency department. The committee finds that clinicians were 4 times more likely to miss MI in women age 60-70 compared to men of the same age. Women were more likely to have a chief complaint of episodic substernal chest pressure exacerbated by mental stress and were incorrectly diagnosed with gastroesophageal reflux disease. Which of the following factors is most likely responsible for this finding?

Question

A quality assurance committee is conducting an assessment of diagnostic errors related to myocardial infarction (MI) in the emergency department.  The committee finds that clinicians were 4 times more likely to miss MI in women age 60-70 compared to men of the same age.  Women were more likely to have a chief complaint of episodic substernal chest pressure exacerbated by mental stress and were incorrectly diagnosed with gastroesophageal reflux disease.  Which of the following factors is most likely responsible for this finding?

Quizplus · Accepted Answer

11ec25c8_d216_cff4_bc81_172d680a0a9d_MD0003_00 Cognitive biases cause up to 70% of diagnostic errors, such as the missed diagnosis of myocardial infarction (MI) seen in this scenario. These biases can result from overdependence on heuristics (ie, mental shortcuts), which are often used to maximize diagnostic efficiency and productivity in busy, complex settings (eg, emergency department). Cognitive bias prevents thorough critical reasoning and workup, leading to misdiagnosis and delayed treatment (up to 80,000 preventable hospital deaths per year in the United States). The underdiagnosis of MI most likely reflects anchoring bias (also known as premature closure), occurring when initial impressions prematurely influence the diagnosis and prevent careful consideration of other possibilities. Anchoring bias can occur when presentations are more subtle (eg, atypical presentations of MI). In this case, initial "anchoring" to symptoms of mental stress prematurely influenced clinicians toward a noncardiac diagnosis (eg, gastroesophageal reflux), precluding proper consideration of MI as a cause of episodic chest pressure. Anchoring bias can be minimized by enhancing clinician awareness (eg, morbidity and mortality review), providing training (eg, simulated cases illustrating biased thinking), and optimizing organizational and workplace factors (eg, limiting distractions). (Choice B) Availability bias (or recency effect) occurs when clinicians' thinking is influenced by recently or frequently seen cases (ie, diagnosing influenza when a patient with fever and dyspnea actually has a pulmonary embolism). Gastroesophageal reflux and MI are both commonly seen in emergency departments; therefore, availability bias is less likely to explain underdiagnosis of MI. (Choice C) Knowledge deficiency is less likely because presentations of MI-including atypical presentations seen in women-are well known in the emergency department setting. Rather, presumptive anchoring to the symptom of mental stress represents a more likely cause of the clinicians' failure to properly consider MI as the diagnosis. (Choice D) Latent errors are system-level factors (eg, inefficient protocols) that cause adverse events. This case describes a series of active errors (ie, clinician misjudgment) caused by cognitive bias, not a system-level error. Educational objective: Anchoring bias occurs when a diagnosis is prematurely swayed by immediate impressions (ie, an anchor). This bias can preclude thoroughly evaluating a differential diagnosis. An example of anchoring bias is prematurely assigning a non-cardiac diagnosis to chest pain associated with mental stress. References: Missed diagnoses of acute cardiac ischemia in the emergency department. (http://www.ncbi.nlm.nih.gov/pubmed/10770981) Cognitive biases associated with medical decisions: a systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/27809908) Cognitive debiasing 1: origins of bias and theory of debiasing. (http://www.ncbi.nlm.nih.gov/pubmed/23882089)

A Quality Assurance Committee Is Conducting an Assessment of Diagnostic