Fifteen years ago, the Institute of Medicine (IOM) published a landmark report “To Err is Human: Building a Safer Health System.” The IOM shocked the world revealing that up to 98,000 humans may die each year as a result of medical errors. That actually came as no surprise to those of us dedicated to patient safety and medical error reduction for the last two decades.As a healthcare provider, one need only pay attention to see that the frequency of errors is obvious. As a healthcare worker with a family member in the hospital, a tally sheet is required if you want to know the real frequency of medical error. Count them up.
The IOM has spoken, again. In a new 369-page report published in September, the IOM again points out the obvious - the problem is the “failure to diagnose.” As an emergency physician with a passion for medical error reduction and patient safety, it was apparent to me 20 years ago the problem was the failure to diagnose! Eighteen years before the IOM published this report suggesting additional clarification on diagnostic issues and problematic reductions, The Sullivan Group analyzed over 400,000 high-risk emergency department patients to identify the cause of the failure to diagnose. That granular analysis provided the road map to improving the diagnostic process that has driven our solutions. This process is already well under way in many healthcare organizations around the country.
In addition, several insurance companies, including The Doctors Company that provided support for the report, have been calling attention to the failure to diagnose issue for many years. Thus, the IOM’s report is not so much a new revelation as it is a call to arms. Fortunately when the IOM speaks, the world listens.
The report calls for an analysis of the diagnostic process, a deep dive into the science of learning and decision-making, a wake-up call to electronic health record companies to join the fight, and a request that any source of potential data to support this process be included in the analysis and solution.
With this kind of attention, perhaps the various key players will wake up and begin to pay attention. From a clinical decision and diagnostic support perspective, the popular electronic health record companies are still crawling out of the primordial ooze. They must play a major role in reducing the failure to diagnose problem.
Research into the diagnostic process will quickly identify low-lying fruit. For example, The Sullivan Group identified and published the fact that there is an inordinate frequency of discharge of patients with very abnormal vital signs from the nation’s emergency departments. The solution is ridiculously simple but requires some human factors engineering. Simply let the nurse and physician know what the vital signs are at the moment of discharge. Create a system whereby at a key moment in patient workflow, the department team, to a certainty, knows the vital signs. Voila, problem solved. No one knowingly discharges very abnormal vital signs!
We are pleased that the IOM has put a spotlight on the failure to diagnose problem. The report however does not mention that many of the problems are apparent and obvious and can be solved right now without double-blind randomized trials. If vital signs are a problem, create a system solution and fix it. If radiology reports of pulmonary lesions are not getting to the primary provider, fix that. Look at the highest risks, evaluate for trends, and go after the obvious fixes. Make our patients safer now to the extent possible and let the research fill in the gaps in the years to come.
