Given that proven effective solutions exist today, why haven't more institutions implemented programs that have proven to reduce diagnostic errors?
I listened with great interest to the interview conducted by Dr. Robert Wachter with Dr. Mark Graber in the January 2016 podcast of “Perspectives on Safety,” also published in the AHRQ PSNet.Dr. Graber makes an excellent point that the data regarding diagnostic errors are statistical estimates based on extrapolation from claims data and a few other sources. We don’t really know the true scope of diagnostic errors. What is worse, the individual physician struggles to understand just what defines a diagnostic error and what they can do to prevent it. As of yet, there is no database or centralized repository for diagnostic errors to refer to and learn from.
Perhaps the most valuable source for diagnostic errors is claims data from malpractice insurers. The excellent suggestion was made in the IOM report Improving Diagnosis in Health Care that “professional liability insurance carriers and captive insurers should collaborate with health care professionals on opportunities to improve diagnostic performance through education, training, and practice improvement approaches and increase participation in such programs.” Such collaborations are underway. Other sources of diagnostic error, such as peer and quality reviews, should also be mined for their valuable lessons relevant to medical practice and disseminated.
The dearth of data related to diagnostic error is certainly a challenge that researchers and clinicians alike will continue to tackle for decades to come. Meanwhile, we have enough information to identify and prevent diagnostic errors – right now, today, even with the limited data available. Drs. Wachter and Graber allude to several of these essential initiatives.
Diagnostic Error Initiatives
The first is awareness. Physicians (and everyone in healthcare) need to know that diagnostic error is a significant threat to patient safety. 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.
The third initiative, included as a recommendation in the IOM report and stressed by Dr. Graber, is education. Be willing to look at things from both the front and back sides of medical errors. At the front door, 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 error.
Then examine the process from the back end – review cases & 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, emergency department, surgery or elsewhere, and customizing the educational program to achieve the greatest impact.
The fourth initiative is to measure performance of clinicians in the steps involved in the diagnostic process, including history-taking, asking risk factors, physical examination, forming a differential diagnosis, ordering and interpreting diagnostic tests, medical decision-making, consultation and disposition. Dr. Graber refers to this as the framework of the diagnostic process, and it can be applied to every high-risk chief complaint or presenting condition. 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 it is the “other guy” 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 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.
The fifth initiative is to utilize clinical decision support whenever possible. Textbooks that comprehensively covered all of medicine in prior centuries could fit into a few score or hundred pages. As Dr. Graber points out, there are between 8,000 and 10,000 different diseases. 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? To be sure, 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.
Drs. Wachter and Graber are to be commended for illuminating the critical issue of diagnostic errors and leading the way to reduce them. As Dr. Graber observes, some suggest that the IOM report should have included more detail and granularity, but it is already nearly 400 pages. We have known for a long time that diagnostic delays and failures are a huge patient safety problem, and the latest report provides ample ammunition to launch an attack. There is no reason to wait for more data or another IOM report before taking action. Dr. Graber says it very well: “…it’s up to the stakeholders to start analyzing what’s in there and taking appropriate action in their domains.”
The world of diagnostic error often seems like insurmountable chaos to individual physicians 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.