Diagnostic Error

By Michael Handler, MD, MMM, FAAPL
CPS Medical Director

As most of you know, the patient safety movement as we know it was started in 1999 with the report "To Err is Human" and was followed in 2001 by its second report, "Crossing the Quality Chasm." The third report in that series was published in September, 2015 and that report, entitled “Improving Diagnosis in Health Care”, was another landmark report in patient safety and the culmination of many years of study of the important process of medical diagnosis.

Basically, this publication addresses in great detail the topic of diagnostic error. Diagnostic error is defined by the IOM as the failure to establish an accurate and timely explanation of the patient’s health problem(s) OR the failure to communicate that explanation to the patient. Although the definition is somewhat controversial in the scholarly circles, the implication of some type of discrepancy in diagnosis is the common denominator and can include over-diagnosis, under-diagnosis or misdiagnosis. And the prevalence is quite staggering. Errors of this type are estimated to be responsible for 40,000 to 80,000 deaths/year in this country. Seventeen percent of adverse events are related to diagnosis and 20% of readmissions are related to the wrong diagnosis. Five percent of primary care visits involve a preventable diagnostic error and ten patients are harmed every day in clinics or emergency departments. It is likely that most of us will experience at least one diagnostic error in our lifetime, sometimes with devastating consequences.

So, I know what you are thinking. It is always the other clinician—not me—who makes errors in diagnosis. In fact, fewer than 10% of physicians admit to one diagnostic error per year and some physicians deny ever making an error. So, what are some of the more common missed diagnoses? Well, missed CVA, epidural abscess, meningitis, sepsis, acute coronary syndrome, abdominal pain and failure to diagnose a cancer, to name a few. Professional liability carriers state that diagnostic errors are second in the number of closed claims and the highest category of average indemnity payment.

When you look at why diagnostic errors occur, you must look at patient variables, system variables and practitioner variables. Patient variables include the stage of disease, how it manifests, how it is described and when help is sought. System complexity includes discounted care, communication barriers, production pressure and difficult access to care and expertise. Finally, practitioner variables include knowledge and experience, access to patient data, tests, consults, skill in clinical reasoning and stress, distractions, mood and time to think. We must also understand the concepts of cognitive biases of providers which lead to error. These biases include such things as anchoring bias which means relying on your initial diagnostic impressions, despite subsequent information to the contrary. These types of biases can lead to errors which perpetuate themselves.

How can we reduce errors? There is not one clear answer, but we can implement processes such as double checks and checklists to reduce reliance on memory and accept feedback from other clinicians whether from physicians, nurses or other professionals. We must also remember to work on improving teamwork, communications and handoffs.

The IOM report concluded with several goals to improve diagnosis and reduce diagnostic error, and these span the entire health care spectrum:

1. Facilitate more effective teamwork in the diagnostic process among professionals, patients and their families.
2. Enhance health care professional education and training in the diagnostic process. Educators are being asked to be sure their curricula include skills in clinical reasoning, teamwork and communication.
3. Ensure health information systems support patients and health care professionals in the diagnostic process. Special reference was made to the elimination of such things as copy and paste, meaningless alerts and templates from the record. Instead, health IT vendors should be encouraged to work together with users to ensure that health IT demonstrates usability, incorporates human factors knowledge and fits well with clinical workflow.
4. Develop and deploy approaches to identify, learn from and reduce diagnostic errors and near misses and establish ways to provide systematic feedback to physicians and other providers in the system. The goal is to find specific actionable items in a root cause analysis and actually fix them.
5. Establish a strong culture of safety that supports the diagnostic process and improvements in diagnostic performance.
6. Develop a reporting environment and medical liability system that facilitates improved diagnosis through learning from errors and near misses.
7. Develop a payment and health care delivery system that supports the diagnostic process and the final goal is to provide dedicated funding for research on the diagnostic process and errors.

So, what are some things that you can do to reduce the incidence of diagnostic errors?

• Work together with all members of the healthcare team to identify, learn from and reduce diagnostic errors. This includes collaboration with all members of the team including physicians, nursing, pharmacy and all other possible sources of information to help with the right diagnosis.
• Sharpen communication skills and improve handoff communication so that nothing is missed which may lead to the right answer.
• Use the electronic health record as a communication tool and not copy and paste just to get the documentation done -- make sure it is correct and true.
• Be willing to accept suggestions and feedback from others, always keeping the best care of our patient top of mind.

The area of diagnostic error continues to be a very dynamic area in patient safety and many unanswered questions remain. We must continue to look for opportunities to help minimize these errors to help to keep all our patients safe.

MICHAEL HANDLER, MD, MMM, FAAPL, is the Medical Director for the Center for Patient Safety. He has been an OB/Gyn physician since 1985, operating private practices in Missouri through 2007. The last ten years Dr. Handler has served as house obstetric physician, medical director for quality improvement, and chief medical officer for several SSM Health hospitals in the St. Louis area. In early 2017 he accepted the position of chief medical officer for Amita Health Alexian Brothers Medical Center and Amita Health St. Alexius Medical Center in suburban Chicago. Dr. Handler earned his medical degree at University of Missouri-Kansas City School of Medicine. He completed his internship and residency in Obstetrics and Gynecology at St. Louis University Hospitals. He has a Master of Medical Management degree from Tulane University and is a fellow of the American College of Physician Executives.