Diagnostic error has
always lurked in the background of the patient safety movement. But in the past
several years there has been a renewed focus on diagnostic error. Now
researchers from Johns Hopkins have analyzed diagnosis-related claims from the
National Practitioner Data Bank (NPDB) and the results are eye-opening (Tehrani
2013). They found that among malpractice claims, diagnostic errors appear
to be the most common, most costly and most dangerous of medical mistakes.
Diagnostic errors include failure to diagnose, wrong diagnosis, delayed
diagnosis, failure to follow up on tests, etc.
Analyzing over
350,000 paid claims over a 25-year period they found diagnostic errors
accounted for 28.6% of the claims, more than any other category. Moreover, they
accounted for 35.2% of the total payments.
Diagnostic errors
more often resulted in death than other categories of malpractice claims.
Significantly, they also found that disability as a result of diagnostic error
was substantial. The authors note that this means previous estimates of the
impact of diagnostic errors were probably significant underestimates because
they were based largely on autopsy studies. Outpatient diagnostic errors
leading to claims were over twice as common as inpatient diagnostic errors,
though the latter were more likely to lead to fatal outcomes.
What’s ironic is
that we often don’t even know about our diagnostic errors unless there is a
malpractice claim. Substantial periods of time typically elapse before it
becomes apparent that a diagnostic error occurred. And it usually becomes
apparent when the patient is elsewhere (another physician’s office, an
emergency room, another hospital, etc.). An angry patient may call you and let
you know about it but more often the patient simply loses confidence in you and
just never returns to you for care. And if we don’t get feedback about our
diagnostic errors or diagnostic accuracy we often get overconfident in our own
abilities. And, of course, many of our diagnostic errors do not result in
patient harm at all. However, they may result in delays and inconveniences.
In our April 2013
What’s New in the Patient Safety World column “AHRQ
Recommended Patient Safety Practices” we noted the ten strategies
identified by the AHRQ project that are "strongly encouraged" for
adoption based on the strength and quality of evidence and twelve other
strategies "encouraged" for adoption based on a slightly lesser
strength and quality of evidence. Strategies targeted at diagnostic errors did
not make the final list but the supplement with the evidence reviews (Annals
of Internal Medicine 2013) did provide a systematic review of those
strategies targeted at diagnostic errors (McDonald
2013). One is really struck by the paucity of good research on
interventions to reduce diagnostic errors or at least identify them before they
lead to patient harm or inconvenience.
Our March 2013
What’s New in the Patient Safety World column “Diagnostic
Error in Primary Care” focused on a study using a trigger tool methodology
to help identify diagnostic errors in primary care settings (Singh
2013). Singh and colleagues make several salient points about interventions
to prevent diagnostic errors. First, given the wide variety of conditions and
presenting symptoms they found in their study it is very unlikely that focusing
solely on specific presentations will be successful in reducing overall errors.
They note that most of the breakdowns occurred in the clinical encounter,
perhaps with time pressures and short encounters contributing to inadequate
decision making. Further yet they note that the trend toward team care and the
patient-centered medical home may not result in the level of cognitive support
needed for complex decision making. And the current levels of technological
decision support for diagnosis are not readily available in most of today’s
electronic medical records.
In our September 28, 2010 Patient Safety Tip of the Week “Diagnostic Error” we highlighted a review of diagnostic error by the Pennsylvania Patient Safety Authority. The PPSA review also provides a couple nice tools to help clinicians identify and avoid diagnostic errors. One is a chart audit tool to help identify errors adopted from the article by Schiff et al (Schiff 2009). The other is a simple checklist the clinician can use to help focus the things he/she needs to do to in each case avoid diagnostic errors.
We hope you’ll look at
some of our prior columns on diagnostic error, listed below, that highlight
some of the work by some excellent researchers (like Mark Graber, Pat
Croskerry, John Ely, Gordon Schiff, Hardeep Singh, Jerry Groopman, Gary Klein
and many others) on the way clinicians
think and the cognitive biases that are important in diagnostic errors. Now
that these recent studies have identified the scope of the problem it is time
to begin focusing on ways to mitigate the problem.
Some of our prior Patient Safety Tips of the Week on diagnostic error:
· September 28, 2010 “Diagnostic Error”
·
November 29,
2011 “More
on Diagnostic Error”
·
May 15, 2012 “Diagnostic
Error Chapter 3”
· May 29, 2008 “If You Do RCA’s or Design Healthcare Processes…Read Gary Klein’s Work”
· August 12, 2008 “Jerome Groopman’s “How Doctors Think”
· August 10, 2010 “It’s Not Always About The Evidence”
·
January 24,
2012 “Patient
Safety in Ambulatory Care”
·
October 9, 2012 “Call
for Focus on Diagnostic Errors”
·
March 2013 “Diagnostic
Error in Primary Care”
· And our review of Malcolm Gladwell’s “Blink” in our Patient Safety Library
References:
Tehrani ASS, Lee HW, Mathews SC, et al. 25-Year summary of US malpractice claims for diagnostic errors 1986–2010: an analysis from the National Practitioner Data Bank
BMJ Qual Saf 2013; Published online 22 April 2013 doi:10.1136/bmjqs-2012-001550
http://qualitysafety.bmj.com/content/early/2013/03/27/bmjqs-2012-001550.short?g=w_qs_ahead_tab
Annals of Internal Medicine. Making Health Care Safer: A Critical Review of Evidence Supporting Strategies to Improve Patient Safety. Annals of Internal Medicine 2013; 158(5_Part_2)
http://annals.org/issue.aspx?journalid=90&issueID=926462&direction=P
McDonald KM, Matesic B, Contopoulos-Ioannidis DG, et al. Patient Safety Strategies Targeted at Diagnostic Errors: A Systematic Review. Ann Intern Med 2013; 158(5_Part_2): 381-389
http://annals.org/data/Journals/AIM/926462/0000605-201303051-00004.pdf
Singh H, Giardina TD, Meyer AND, et al. Types and Origins of Diagnostic Errors in Primary Care Settings. JAMA Intern Med 2013; published online February 25, 2013
http://archinte.jamanetwork.com/article.aspx?articleid=1656540
Pennsylvania Patient Safety Authority (PPSA). Diagnostic Error in Acute Care. Pa Patient Saf Advis 2010 Sep;7(3):76-86
http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2010/Sep7%283%29/Pages/76.aspx
Schiff GD, Hasan O, Kim S; et al. Diagnostic Error in Medicine: Analysis of 583 Physician-Reported Errors. Arch Intern Med, Nov 2009; 169: 1881 – 1887
DEER Taxonomy Chart Audit Tool
http://patientsafetyauthority.org/EducationalTools/PatientSafetyTools/diagnosis/Documents/audit.pdf
Pennsylvania Patient Safety Authority. A Physician Checklist for Diagnosis.
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