## Introduction

Diagnostic error in medicine is conservatively estimated at 15% (Newman-Toker) while the actual number may be considerably higher(Winters, Newman). Checklists have been demonstrated to reduce error in procedural areas of medicine yet, utilization remains limited (Ely, Gaw 2009 ). To measure usefulness in diagnosis in neurologic disease, a computer generated differential diagnostic checklist utilizing NeurologicDx.com, an open access internet based program (www.NeurologicDx.com) is compared to physician recall in third year neurology residents and practicing neurologists. This study demonstrates checklist programs can impact neurologic diagnosis when compared to physician recall alone.

**Background**

Checklists have been demonstrated effective in procedural aspects of medicine, yet implementation has not been fully embraced and diagnostic capability not systematically studied.

**Objective**

To assess the potential of a diagnostic checklist by comparing physician recall to a computer generated differential diagnostic program, NeurologicDx.

**Methods**

A group of 12 PGY4 resident and practicing neurologists were each given a sheet of paper which contained the single instruction “List as many neurologic diseases associated with each term below”. There were three terms, one at the top of each of three columns with 10 blank lines drawn below. Participants were asked to indicate their time in practice as either PGY4 for third year residents or decades in practice for attending physicians. The terms, “jaundice”, “night sweats”, and “oval pupil” were used without a time limit for completion. Each of the answers provided by participants would be validated by Google search.

Jaundice |
NDx |
Physicians |

autoimmune cholangiitis | N | 1 |

B 12 deficiency | Y | 0 |

carbamazepine,toxicity | Y | 0 |

carcinoid tumor | Y | 0 |

central pontine myelinolysis | Y | 0 |

cerebrovascular accident | Y | 0 |

coma | Y | 0 |

Crigler-Najjar disease,type I | Y | 0 |

hemachromatosis | N | 2 |

hemoglobin abnormality,neurologic complications of | Y | 0 |

hemolytic anemia | N | 1 |

hemorrhage,intracranial,newborn | Y | 0 |

hepatic encephalopathy | Y | 10 |

hepatitis | Y | 3 |

hepatolenticular degeneration(Wilson’s disease) | Y | 3 |

HIV | N | 1 |

hyperammonemia | N | 1 |

hyperbilirubinemia,CNS abnormality after | N | 1 |

infectious mononucleosis | Y | 0 |

kernicterus | Y | 4 |

leptospirosis | Y | 0 |

liver disease | Y | 0 |

malaria | N | 1 |

medications | Y | 1 |

mushroom poisoning | Y | 0 |

neurofibromatosis 1 | Y | 0 |

Niemann-Pick disease | Y | 0 |

obstructive CBD | N | 1 |

phenylketonuria | N | 1 |

portal hypertension | N | 1 |

sickle cell disease | N | 1 |

sodium valproate,toxicity | Y | 0 |

syphilis | N | 1 |

thrombotic thrombocytopenia purpura | Y | 0 |

trichopoliodystrophy | Y | 0 |

Night sweats |
NDx |
Physicians |

acquired immunodeficiency syndrome | Y | 0 |

angiitis,granulomatous of CNS | Y | 0 |

arteritides | Y | 0 |

aspergillosis | Y | 0 |

bacterial endocarditis | Y | 1 |

brain metastasis | N | 1 |

brucellosis | Y | 0 |

carcinoid syndrome | N | 1 |

coccidioidomycosis | Y | 0 |

cryptococcal meningitis | Y | 0 |

drug induced | N | 2 |

dysautonomia | N | 2 |

empyema,epidural-spinal | Y | 0 |

encephalopathy | N | 1 |

hepatitis | Y | 0 |

Hodgkin’s disease,neurologic involvement with | Y | 0 |

human immunodeficiency virus type 1 | Y | 2 |

limbic encephalitis | Y | 0 |

lyme disease | N | 1 |

lymphoma | Y | 7 |

lymphomatoid granulomatosis | Y | 0 |

malaria | N | 2 |

meningitis | Y | 2 |

mononeuritis multiplex | Y | 0 |

myelitis | Y | 0 |

neoplastic angioendotheliosis | Y | 0 |

neurologic complications of,chronic pulmonary disease | Y | 0 |

osteomyelitis,spinal | Y | 0 |

Parkinson disease | Y | 1 |

periarteritis nodosa | Y | 0 |

pituitary,metastasis to | Y | 0 |

polymyalgia rheumatica | Y | 0 |

streptococcal infection | Y | 0 |

striatal encephalitis | Y | 0 |

syphilis | N | 1 |

temporal arteritis | Y | 1 |

toxoplasmosis,CNS | Y | 0 |

tuberculosis | Y | 9 |

Waldenstrom’s macroglobulinemia | Y | 0 |

West Nile fever | Y | 0 |

Whipple’s disease | Y | 0 |

Oval pupil |
NDx |
Physicians |

Aides pupil | Y | 1 |

Argyll Robertson pupil | Y | 0 |

cerebrovascular accident | Y | 0 |

congenital | N | 2 |

diabetes | Y | 1 |

glaucoma | Y | 0 |

intracerebral hemorrhage | Y | 0 |

midbrain,hemorrhage | Y | 0 |

midbrain,infarction of | Y | 0 |

post-surgical | N | 2 |

Ross syndrome | Y | 0 |

syphilis | Y | 5 |

uncal herniation | Y | 0 |

**Summary**

Computer generated checklists can be used to expand the information available at point of care to remind physicians of significant items to add to their differential diagnosis. The overall suggestion is that computer generated checklists will significantly improve diagnostic capability, shorten time for appropriate care and reduce error.

## References

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