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By U. Ingvar. Western Baptist College.

They also suggest that our statistics concerning mortality resulting from medical errors may be in fact be conservative figures cheap premarin 0.625 mg mastercard. An article in Psychiatric Times (April 2000) outlines the stakes involved in reporting medical errors cheap 0.625mg premarin mastercard. General Accounting Office responsible for health financing and public health issues, testified before a House subcommittee hearing on medical errors that "the full magnitude of their threat to the American public is unknown” and "gathering valid and useful information about adverse events is extremely difficult. A survey of nurses found that they also fail to report medical mistakes for fear of retaliation. Pharmacology texts also will tell doctors how hard it is to separate drug side effects from disease symptoms. Treatment failure is most often attributed to the disease and not the drug or doctor. Doctors are warned, “Probably nowhere else in professional life are mistakes so easily hidden, even from ourselves. Jay Cohen, who has extensively researched adverse drug reactions, notes that because only 5% of adverse drug reactions are reported, there are in fact 5 million medication reactions each year. Dorothea Wild surveyed medical residents at a community hospital in Connecticut and found that only half were aware that the hospital had a medical error-reporting system, and that the vast majority did not use it at all. Wild adds that error reporting is the first step in locating the gaps in the medical system and fixing them. With the discovery of the “germ theory,” medical scientists convinced the public that infectious organisms were the cause of illness. Medication Errors A survey of a 1992 national pharmacy database found a total of 429,827 medication errors from 1,081 hospitals. The error rate intercepted by pharmacists in this study was 24%, making the potential minimum number of patients harmed by prescription drugs 417,908. A 2003 study followed 400 patients after discharge from a tertiary care hospital setting (requiring highly specialized skills, technology, or support services). Reuters also reported that prior research has suggested that nearly 5% of hospital admissions (over 1 million per year) are the result of drug side effects. The study found that one of the reasons for this failure is that in nearly two-thirds of the cases, doctors could not diagnose drug side effects or the side effects persisted because the doctor failed to heed the warning signs. Often, instead of gaining relief, they fall victim to the myriad iatrogenic side effects of antidepressant medication. Moreover, a whole generation of antidepressant users has been created from young people growing up on Ritalin. Medicating youth and modifying their emotions must have some impact on how they learn to deal with their feelings. As adults, these medicated youth reach for alcohol, drugs, or even street drugs to cope. Television Diagnosis To reach the widest audience possible, drug companies are no longer just targeting medical doctors with their marketing of antidepressants. By 1995, drug companies had tripled the amount of money allotted to direct advertising of prescription drugs to consumers. While the drug companies maintain that direct-to-consumer advertising is educational, Dr. Another aspect of scientific medicine that the public takes for granted is the testing of new drugs. Drugs generally are tested on individuals who are fairly healthy and not on other medications that could interfere with findings. But when these new drugs are declared “safe” and enter the drug prescription books, they are naturally going to be used by people who are on a variety of other medications and have a lot of other health problems. Then a new phase of drug testing called “post-approval” comes into play, which is the documentation of side effects once drugs hit the market. Agger reminds us that low concentrations of antibiotics are measurable in many of our foods and in various waterways around the world, much of it seeping in from animal farms.

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Critical appraisal of the literature and good medical decision making require an understanding of the basic tools of probability order premarin 0.625 mg without prescription. It is virtually impossible to describe the operations of a given biological system with a single trusted 0.625 mg premarin, simple formula. Since we cannot mea- sure all the parameters of every biological system we are interested in, we make approximations and deduce how often they are true. Because of the innate vari- ation in biological organisms it is hard to tell real differences in a system from random variation or noise. Statistics seek to describe this randomness by telling us how much noise there is in the measurements we make of a system. By filter- ing out this noise, statistics allow us to approach a correct value of the underlying facts of interest. These include techniques for graphically displaying the results of a study and mathematical indices that summarize the data with a few key numbers. These key numbers are measures of central tendency such as the mean, median,andmode and measures of dispersion such as standard devia- tion, standard error of the mean, range, percentile,andquartile. In medicine, researchers usually study a small number of patients with a given disease, a sample. What researchers are actually interested in finding out is how the entire population of patients with that disease will respond. Researchers often compare two samples for different characteristics such as use of certain therapies or exposure to a risk factor to determine if these changes will be present in the population. Inferential statistics are used to determine whether or not any differences between the research samples are due to chance or if there is a true difference present. Also inferential statistics are used to determine if the data gathered can be generalized from the sample to a larger group of subjects or the entire population. Visual display of data The purpose of a graph is to visually display the data in a form that allows the observer to draw conclusions about the data. The reader is responsible for evaluating the accu- racy and truthfulness of graphic representations of the data. A lack of a well-defined zero point makes small differences look bigger by emphasizing only the upper portion of the scale. It is proper to start at zero, break the line up with two diagonal hash marks just above the zero point, and then continue from a higher value (as in Fig. This still exaggerates the changes in the graph, but now the reader is warned and will consider the results accordingly. Lack of pro- portionality, a much more subtle technique than lack of a well-defined zero, is also improper. It serves to emphasize the drawn-out axis relative to the other less drawn-out axis. This visually exaggerates smaller changes in the axis that is drawn to the larger scale (Fig. Therefore, both axes should have their vari- ables drawn to roughly the same scale (Fig. This makes the change in mean final exam scores appear to be much greater (relatively) than 80 they truly are. Although the change in mean final exam scores still appears to 80 be relatively greater than they truly are, the reader is notified that this distortion is occurring. This consists of the use of three-dimensional shapes to demon- strate the difference between two groups, usually the effect of a drug on a patient outcome. One example uses cones of different heights to demonstrate the dif- ference between the endpoint of therapy for the drug produced by the company and its closest competitor. Visually, the cones represent a larger volume than sim- ple bars or even triangles, making the drug being advertised look like it caused a much larger effect. This makes it appear as if the change in mean 80 final exam scores occurred over a much shorter time period than in reality. The stem is made up of the digits on the left side of each value (tens, hundreds, or higher) and the leaves are the digits on the right side (units, or lower) of each number. Let’s take, for example, the following grades on a hypothetical statistics exam: Review of basic statistics 97 Fig. In creating the stem-and-leaf plot, first list the tens digits, and then next to them all the units digits which have that ‘tens’ digit in common.

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Nolan advo- Although students and residents excel at this exercise buy premarin 0.625 mg mastercard, they cates 3 main strategies based on a systems approach: pre- rarely use it outside the classroom or teaching rounds buy premarin 0.625mg amex. As vention, making error visible, and mitigating the effects of we discussed earlier, with more experience, clinicians begin error. Most of the cognitive strategies described above fall to use a pattern-recognition approach rather than an exhaus- into the category of prevention. Other examples of cognitive The systems approaches described below fall chiefly into forcing strategies include advice to always “consider the the latter two of Nolan’s strategies. One approach is to opposite,” or ask “what diagnosis can I not afford to provide expert consultation to the physician. Usually a diagnostic decision-sup- only in artificial situations and many of them have been per- port system is used once the error is visible (e. The history of these systems is reflective of the overall Using the system may prevent an initial misdiagnosis and problem we have demonstrated in other domains: despite may also mitigate possible sequelae. A variety they do use them, many physicians are simply reluctant to of diagnostic decision-support systems were developed out 181 use decision-support tools in practice. Miller’s overall conclusions were that while data on how often they are used compared with how often the niche systems for well-defined specific areas were they could/should have been used. The title, “A Report Card on data into the programs, it is likely that their usage would be Computer-Assisted Diagnosis—The Grade Is C,” of Kas- even lower or that the data entry may be incomplete. In a subsequent study, Berner tering, because what is usually displayed is a (sometimes 167 and colleagues found that less experienced physicians lengthy) list of diagnostic considerations. Also, as Teich and colleagues noted with of the Iliad system in educational settings. More disturbing was potentially useful, but the limited interest in them has made that use of the system actually increased costs, perhaps by several commercial ventures unsustainable. Because such puzzles occur rarely, which was initially begun as a pediatric system and now is there is not enough use of the systems in real practice 174–178 also available for use in adults. A second general category of a 179 180 Miller and Berner have reviewed the challenges in systems approach is to design systems to provide feedback evaluating medical diagnostic programs. Overconfidence represents a mismatch be- ficult to determine the gold standard against which the systems tween perceived and actual performance. It is a state of should be evaluated, but both investigators advocate that the miscalibration that, according to existing paradigms of cog- criterion should be how well the clinician using the computer nitive psychology, should be correctable by providing feed- 179,180 compares with use of only his/her own cognition. In this program, radiologists keep back can improve the basis on which the clinicians are track of their agreement with any prior imaging studies they judging the frequency of events, which may improve re-review while they are evaluating a current study, and the calibration. In this framework, a possible approach to reducing diagnostic error, overconfidence, and Pathology. Experiments confirm that feedback can improve perfor- 184 This act mandated more rigorous quality measures in regard mance, especially if the feedback includes cognitive in- to cytopathology, including proficiency testing and manda- formation (for example, why a certain diagnosis is favored) 189 tory reviews of negative smears. Even with these mea- as opposed to simple feedback on whether the diagnosis was 185,186 sures in place, however, rescreening of randomly selected correct or not. A recent investigation by Sieck and 131 smears discloses a discordance rate in the range of 10% to Arkes, however, emphasizes that overconfidence is 30%, although only a fraction of these discordances have highly ingrained and often resistant to amelioration by sim- 190 major clinical impact. There are no comparable proficiency requirements for The timing of feedback is important. Immediate feed- 187 anatomic pathology, other than the voluntary “Q-Probes” back is effective, delayed feedback less so. Q-Probes are highly focused re- feedback often is not available at all, much less immediately views that examine individual aspects of diagnostic testing, or soon after the diagnosis is made. In fact, the gold stan- including preanalytical, analytical, and postanalytical er- dard for feedback regarding clinical judgment is the au- rors. Q-Tracks are monitors that “reach beyond the testing some cases adopted, as a method of improving performance phase to evaluate the processes both within and beyond the 191 and calibration. The accuracy of radiologic diagnosis is most isons with all other participating labs. Several monitors sharply focused in the area of mammography, where both evaluate the accuracy of diagnosis by clinical pathologists false-positive and false-negative reports have substantial and cytopathologists. In considering the reasons for this difference in performance, the authors point out that 85% of smears have been available commercially for a number of mammographers in the United Kingdom voluntarily partic- years. A recently completed randomized trial of 30 mammographers is 5,000 mammograms per year. Pap smear results showed a very slight advantage of the 194 As an initial step toward performance improvement by computer programs over unaided cytopathologists, but providing organized feedback, the American College of earlier reports of the trial before completion did not show Berner and Graber Overconfidence as a Cause of Diagnostic Error in Medicine S15 193 any differences.

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