Properly diagnosing a patient's problems is such a basic and fundamental aspect of providing care and, yet, the health care system is missing the mark at an alarming rate. A new report — from the people who brought you the landmark "To Err is Human," which ratcheted up the patient safety movement — think they know how to fix it.
Some 5 percent of U.S. adults who seek outpatient care experience a diagnostic error, according to Improving Diagnosis in Health Care, issued Tuesday morning by the Institute of Medicine. The results of those mistakes can be dire, contributing to about 10 percent of patient deaths and costing the health care system an average of nearly $387,000 each time, the leading type of medical malpractice claim.
The examples of such cases are heartbreaking: One 33-year-old obese patient with a history of asthma showed up at the doc's office with thigh pain and red streaking on her skin. Her primary care physician thought it was an asthma flare, but she died in the emergency department later that day from a blockage in her arteries. In another case, an emergency physician brushed off a 28-year-old female patient, sent from a nearby addiction treatment center after complaining of chest pain. He scolded the young woman for needlessly tying up the ED, diagnosing her with an "anxiety state," and sent her back to the treatment center. She died later that evening from blockage in her arteries.
Hospitals and physician practices have done a poor job of addressing such errors, authors contend, because of sparse data on the topic, few reliable measures and mistakes that are often discovered in retrospect. Members involved with the committee that produced the report — who come from organizations ranging from Kaiser to Harvard and the Veterans Health Administration — want to chart a course toward remedying those roadblocks.
"We hope it's going to be a wake-up call," says John Ball, M.D., chairman of the committee and executive vice president emeritus of the American College of Physicians. "One of our main surprises was that there had not been more done about this. We hope the major thrust from the report will be to wake up people and say, 'Hey, we're shining a light on this as an important issue in health care, and calling on a variety of stakeholders to start doing something about it.' "
Numerous factors could lead to such errors, the report notes, including inadequate communication between clinicians and patients, an ill-designed system to support the diagnostic process, limited feedback to doctors about the accuracy of their conclusions, and a culture that discourages transparency and impedes any attempts to improve.
Authors spell out eight goals the health care system must pursue to bolster diagnoses and reduce corresponding errors, which are defined as "the failure to establish an accurate and timely explanation of the patient's health problem(s) or communicate that explanation to the patient":
1. Facilitate more effective teamwork in the diagnostic process among health care professionals, patients and their families.
2. Enhance health care professional education and training in the diagnostic process.
3. Ensure that health IT supports patients and professionals in the diagnostic process.
4. Develop and deploy approaches to identify, learn from and reduce diagnostic errors and near-misses in clinical practice.
5. Establish a work system and culture 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 diagnostic errors and near-misses.
7. Design a payment and care delivery environment that supports the diagnostic process.
8. Provide dedicated funding for research on the diagnostic process and diagnostic errors.
The report lays out several next steps for the field to act on to make sure recommendations are put into place, including a series of forums on the topic, scholarly articles to keep the conversation going, and urging federal agencies to develop a research agenda on diagnostic errors by the end of 2016. The main takeaway for hospital leaders, Ball says, is that they must foster a culture that discourages opaqueness and supports continuous learning and improvement.
"One of the most important recommendations is to build a learning organization with a nonpunitive culture, an organization where, when errors are found, they're celebrated because you can learn from them and change things for the better," Ball says. "Leadership makes a difference; if the top of the organization, on the management, board and clinical side, takes improvement as a goal, then you're going to be better off."
Industry watchers across the field applauded the group’s efforts to take on such a thorny issue. Mark Graber, M.D., founder and president of the Society to Improve Diagnosis in Medicine, in a statement called the report a “major milestone” in efforts to address “one of the most difficult and complex tasks in health care,” involving thousands of possible tests, and many more potential diagnoses.
“Today’s report shines a spotlight on the importance of getting the diagnosis right,” says John Combes, M.D., chief medical officer, American Hospital Association. “Diagnosis is both an art and a science. Better understanding of how a diagnosis is formulated through complex critical thinking will also assist in improving diagnostic accuracy.”