Diagnostic Error: Chaos or Conquerable?

Effective solutions to combat diagnostic error exist today. Why haven't more institutions implemented programs with a focus on diagnostic error reduction?

There are several reasons, but certainly one has been a lack of data. Historically, data regarding diagnostic errors consisted of statistical estimates based on extrapolation from malpractice claims data and a few other sources. We have not had insight into the true scope of diagnostic errors. As a result, the individual practitioner struggles to understand just what defines a diagnostic error and what they can do to prevent it. Recent research into the cause of diagnostic errors is beginning to fill that void.

Recent publications out of Johns Hopkins provide new data-driven insights into the frequency and nature of diagnostic error in emergency medicine. Dr. Newman-Toker et al. published a systematic review of diagnostic errors in the emergency department (ED). Based on an analysis of 279 studies, the top 15 clinical conditions associated with serious misdiagnosis-related harms (accounting for 68% of serious harms) were (1) stroke, (2) myocardial infarction, (3) aortic aneurysm and dissection, (4) spinal cord compression and injury, (5) venous thromboembolism, (6) meningitis and encephalitis, (7) sepsis, (8) lung cancer, (9) traumatic brain injury and traumatic intracranial hemorrhage, (10) arterial thromboembolism, (11) spinal and intracranial abscess, (12) cardiac arrhythmia, (13) pneumonia, (14) gastrointestinal perforation and rupture, and (15) intestinal obstruction.

An estimated 5.7% of all ED visits had at least one diagnostic error. Error rates ranged from 1.5% for myocardial infarction to 56% for spinal abscess. There was wide variation between hospitals. This data syncs up well with The Sullivan Group’s (TSG) experience over the last two decades and with prior research from Dr. Newman-Toker indicating that spinal epidural abscess is missed on the first visit in 62% of cases, acute aortic dissection in 28% of cases, and pulmonary embolism in 20% of cases. On the single critical issue of vital signs, internal research from TSG indicates that over 10% of adult patients and 15% of pediatric patients are discharged with an abnormal pulse or respiratory rate. In our view, the 5.7% error rate cited by Newman-Toker is not surprising.

Although the emergency medicine community took issue with some of Newman Toker’s methods and conclusions, this work begins to bring a data-based focus to addressing the issue of diagnostic error in and beyond emergency medicine. The diagnostic error issue is a very real problem that impacts both patients and healthcare providers. We suggest that there are steps individual practitioners and organizations can take to reduce the error rate and keep our patients safe.

Diagnostic Error Initiatives

1. Awareness - The first initiative is awareness. Physicians (and everyone in healthcare) need to know that diagnostic error is a significant threat to patient safety.
2. Self-Awareness - The second is self-awareness—to realize that it is “very likely that each of us will have a diagnostic error in our lifetime” and to quit rationalizing “away some of the mistakes that are made.” Accept that you will make cognitive errors; be willing to think about your own thinking (metacognition) and move beyond denial to become a better clinician.
3. Education - The third initiative is education. Be willing to look at things from both the front and back sides of medical errors. At the front side, this means going beyond the didactics of textbooks to include learning (or re-learning): the fundamentals of the diagnostic process; where it goes wrong; how omissions and errors along the diagnostic pathway accumulate and lead to diagnostic delays or failures; and how poor communication, cognitive errors, and handoff and system errors can all contribute to diagnostic errors.Then examine the process from the back end—review cases and claims with adverse outcomes to analyze if and how they could have been prevented. Involve the entire team, department, service line, and institution in the ongoing educational process. Start by targeting the highest risk clinical areas—such as OB, ED, surgery or elsewhere—and customizing the educational program to achieve the greatest impact.
4. Data - The fourth initiative is to get the data. Measure the performance of clinicians in the steps involved in the diagnostic process, including history-taking, asking about risk factors, physical examination, forming a differential diagnosis, ordering and interpreting diagnostic tests, medical decision-making, consultation ,and disposition. Determining competence and compliance with these key steps is critical in providing practitioners with objective data regarding their performance and comparing it to their peers locally and even nationally. Nearly everyone believes they are a superior clinician and that it is the “other doc” that makes mistakes, until you show them their own performance data. We have found most often that this step is the turning point—the epiphany—when an individual or a department or an institution finally accepts that they have a problem and can actually improve their performance with objective results. They are now ready for action. If this step is not reached, there is limited value in going beyond.
5. Decision Support - The fifth initiative is to utilize clinical decision support whenever possible. How is a clinician realistically supposed to remember all the risk factors for pulmonary embolism much less diagnose an uncommon condition they have never seen? Without a doubt, the computer is no panacea for risk and safety, but there is hope that in the near future we will see rapid, useful, point-of-care clinical decision support that will augment the brain and tools currently used by clinicians.

The world of diagnostic error often seems like insurmountable chaos to individual practitioners and healthcare systems alike, but the solution can start with conquerable, concrete initiatives. Action can begin with initiative #1—awareness of the problem—followed by initiative #2—self-awareness.

While these topics have received increased attention lately, The Sullivan Group has recognized for decades that diagnostic error is a major threat to patient safety and that delays and failures in diagnosis are the core allegations in many malpractice suits. We have addressed diagnostic errors with a comprehensive program that includes online education, clinical decision tools, and performance improvement. Contact us to learn more about implementing our proven solutions to impact clinical practice within your organization.

References

Newman-Toker DE, Peterson SM, Badihian S, et al. Diagnostic Errors in the Emergency Department: A Systematic Review [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2022 Dec. (Comparative Effectiveness Review, No. 258.) Available from: https://www.ncbi.nlm.nih.gov/books/NBK588118/ doi: 10.23970/AHRQEPCCER258.

Newman-Toker DE, Schaffer AC, Yu-Moe CW, Nassery N, Saber Tehrani AS, Clemens GD, Wang Z, Zhu Y, Fanai M, Siegal D. Serious misdiagnosis-related harms in malpractice claims: The "Big Three" - vascular events, infections, and cancers. Diagnosis (Berl). 2019 Aug 27;6(3):227-240. doi: 10.1515/dx-2019-0019. Erratum in: Diagnosis (Berl). 2020 May 16;8(1):127-128. PMID: 31535832.