"Patient Safety Update"

Diagnostic Errors Get Attention As Next Patient Safety Goal

Errors in diagnosis estimated to be responsible for between 40,000 and 90,000 deaths yearly

PHYSICIAN LEADERS IN PATIENT SAFETY are turning up the heat on doctors to reduce the incidence of diagnostic errors. This is a topic few dared to openly discuss until recently. It is directly linked to Medicare and private payer efforts to crack down on medical errors.

This development has profound consequences for pathologists and laboratory executives. As physicians come under pressure to reduce errors in diagnosis, they will need more sophisticated support from their clinical laboratory. In turn, this will bring pathologists closer to treatment settings as valued consultants in diagnosis.

Admittedly, the campaign to make reduction of diagnostic errors is in its infancy. For example, a supplement to the May 2008 issue of The American Journal of Medicine (AJM) first opened this delicate subject with a compilation of papers discussing why the sensitive issue of diagnostic errors is rarely discussed, as well as why it has been understudied.

Writing in AJM, guest editors Mark L. Graber, M.D., a faculty member at SUNY Stony Book, and Eta S. Berner, Ed.D., faculty member in the School of Health Professions at the University of Alabama at Birmingham, noted that, on a basic level, physicians tend to be overly confident about their own skills and are complacent because they fail to recognize the prevalence of the problems.

“The fact that most of their diagnoses are correct, and that effective feedback regarding their errors is lacking, reinforces this inclination,” they said. “When directly questioned, many clinicians find it incon- ceivable that their own error rate could be as high as the literature demonstrates.”

Graber and Berner further explained, “They [physicians] acknowledge that diagnostic errors exist [in their own practice], but believe their rate is very low, and that any errors are made by others who are less skillful or less careful.”

Call For Immediate Action

Now two respected physician leaders in the patient safety movement have called for immediate action in an op-ed article, published in the March 11, 2009, issue of Journal of the America Medical Association (JAMA). From Johns Hopkins School of Medicine, David Newman-Toker, M.D., Ph.D., and Peter Pronovost, M.D., Ph.D., emphasized that the problems caused by errors in diagnosis are much bigger in terms of deaths than more popular targets, like medication errors and wrong-site surgeries.

Diagnostic errors—including missed, wrong, or delayed diagnoses—account for an estimated 40,000 to 90,000 deaths a year. Diagnostic errors trigger nearly twice as many tort claims as medication errors and also subject patients to medical complications, as well as the discomfort and cost of medical tests they don’t need.

Papers published in the May 2008 supplement of AJM confirm the extent of diagnostic errors. These authors suggested improvement will best come by developing systems to provide physicians with better feedback on their own errors.

According to the AJM papers, the diagnostic error rate is generally less than 5% in the perceptual specialties, such as pathology, radiology, and dermatology. However, the diagnostic error rate can reach as high as 10% to 15% in medical specialties.

These papers also pointed out that medical practitioners do not utilize systems designed to aid in diagnostic decisions. “In my view, diagnostic error will be reduced only if physicians have a more realistic understanding of the amount of diagnostic errors they personally make,” contended Paul Mongerson, a retired engineer.

In 1980, as a patient facing an apparent diagnosis of pancreatic cancer, Mongerson created a matrix chart of his symptoms and test results to assess the probability that his doctors were right. He didn’t think so and did not undergo surgey. Mongerson later created a foundation to promote computer- based and other strategies to reduce diagnostic errors.

At Johns Hopkins, Newman-Toker and Pronovost recommended moving beyond blaming doctors, which hasn’t produced any solutions. They asserted that reducing diagnostic errors will require a focus on larger “system” failures that affect the practice of medicine overall. This is similar to the approach to reducing medication and other treatment errors.

Improve Diagnostic Accuracy

“Moving away from a model that chastises individual physicians to one that focuses on improving the medical system as a whole could offer big payoffs for improving diagnostic accuracy, as well as the cost effectiveness of care,” said Newman-Toker, Assistant Professor of Neurology, Otolaryngology, Health Sciences Informatics, Epidemiology and Health Policy and Management at Johns Hopkins School of Medicine and Johns Hopkins Bloomberg School of Public Health.

The Johns Hopkins team recommended systematically adopting tools like checklists to help physicians remember critical diagnoses. They noted that hospitals successfully reduced bloodstream infections in intensive care patients by requiring physicians to follow a procedural checklist that emphasizes sterile techniques when inserting medical catheters in these patients.

They also recommended making computers with diagnostic-decision support systems available to assist physicians in calculating the level of risk for patients with certain diseases.

Realign Resources

“Right now, there is often a mismatch between who gets advanced diagnostic testing and who needs it, leading to worse outcomes and higher costs,” Newman-Toker said.“Realigning resources with needs would improve outcomes at a lower cost.”

He explained, for example, that triage protocols in emergency departments often lump patients with typically benign symptoms like headache into the “low-risk” category, even though headache can be indicative of serious conditions like a bleeding brain aneurysm. Newman-Toker suggested that one systemic fix to decrease diagnostic errors would be to create different triage rules for “low-risk” and “high-risk” patients presenting with a headache. There would be detailed criteria for distinguishing between the two categories.

The Johns Hopkins physicians said that health systems could further decrease diagnostic errors with time-tested, low-tech tools such as independent second looks at X-rays and CT scans or by rapidly directing patients with unusual symptoms to diag- nostic experts. Pathologists obviously would be among diagnostic consultants in high demand, advising physicians about the most appropriate laboratory tests to perform, helping to interpret results, and to select treatment options.

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