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At the beginning of March, Mark Graber, MD, got a call from The Joint Commission informing him that he was one of the winners of the John M. Eisenberg awards for patient safety and quality. This individual achievement was given to Graber because of his extensive work in the field of recognizing, measuring, and finding ways to minimize diagnostic errors in healthcare. It is a topic that hasn’t gotten a lot of press up until now, but which Graber told Hospital Peer Review he thinks will be at the forefront of quality efforts in the near future. “The award is a fantastic honor and can only help raise awareness about the importance of diagnostic quality,” he says. “This is a time for every healthcare organization to just ask: ‘What are we doing here to address the problem?’”
Adding importance to the weight of the award is a pending report from the Institute of Medicine, due out sometime this year, that will look at the issue of diagnostic errors. It’s a topic that is gaining momentum.
Last month, we talked to Graber about the issue of diagnostic errors, and in our conversation, he mentioned one facility, Maine Medical Center, that had done a great job at getting physicians to not just accept the notion that they might get things wrong, but to actually count their errors, report them, and then dissect each one in order to learn from it.
The effort was led by Robert Trowbridge, MD, director of the division of general internal medicine at the 600-bed hospital in Portland, ME. For six months in 2010, providers were educated on the issues surrounding diagnostic errors as outlined in existing literature, and the potential impacts such mistakes could have on patients.
M&M conferences were redesigned, Trowbridge explained, so that the conversations spent more time focusing on issues surrounding diagnosis and potential mistakes made in that arena. Interns and medical students spent more learning time on the issue, as well. All physicians spent some time learning how to improve their clinical reasoning skills, as well as what common errors were and how to avoid them. Coupled with the learning was a more robust root cause analysis program designed specifically for situations involving diagnostic error. The new method includes looking at potential errors in cognition, as well as system-related errors.
Initially, Trowbridge says, they had trouble finding errors. “Usually, nurses are the reporters of mistakes, but physicians are the experts in diagnosis,” he explains. So they corralled a couple physician champions and developed a physician reporting system. Physicians fill out a basic screen that includes the patient name, the medical record number, the type of error — missed, wrong or delayed diagnosis — and a brief description of the problem. For example, if an iron deficiency was missed over the course of a year and the patient ended up with late-stage colon cancer, that would be a delayed diagnostic error. “Most error reporting has something like 17 fields, and is on software our physicians aren’t familiar with. But this sits on the clinical desktop and is familiar to the doctors.”
The reporting is completely anonymous, and the identifying information was eliminated as soon as the relevant information on the kind of error was collected, Trowbridge says. “We counted for six months and found a lot of errors we wouldn’t have found otherwise,” he says.
That they were finding them was gratifying. “We know that diagnostic errors run at about 10-15%, but they are rarely found in compilations of sentinel events. That means they are happening, but we are not capturing them as a means for improving quality. And if we aren’t capturing them, we can’t improve them.” Physicians know they exist and they aren’t saying anything about them. That may be due to the culture of blame in some hospitals and systems, but since physicians want to do the right thing by their patients, Trowbridge isn’t sure if that explains all of it.
“I expected push-back from physicians on this and didn’t get it,” he says. “This wasn’t in the lexicon before, but it is now. We piloted it with the adult inpatient medical group and were clear that there would be no individual attribution of errors. But some of them wanted that depth of data. But we left no electronic trail, and all paper with identifying information was destroyed. We spent a long time talking to counsel about this project before we started.”
While the notion was to input your own errors, the system was designed so that anyone could input an error they saw happen. But Trowbridge says he doubts the icon they used for reporting the error would have been widely known outside the physician community, and therefore it’s unlikely anyone aside from doctors ever reported an error.
It was labor-intensive, and Trowbridge says if he wasn’t walking around reminding physicians to report their diagnostic errors, the reporting rate would fall off. But the issue remained in the consciousness of the physicians regardless. M&M conferences remain different, with someone talking about the contribution of diagnostic error to a case. The pilot ran for six months. People still report, but not at the rate that happened during the pilot.
They are using a different reporting system that includes a spot for diagnostic errors in the same reporting system that reports medication errors, wrong-site surgeries, and other sentinel events. It still doesn’t include women’s, pediatrics, or surgical specialties — just the adult inpatient population.
“You have to look at this, and the best way to do this would be a multimodal measurement system,” Trowbridge says. “You should have triggers — like certain types of diagnoses — or specific presentations that you investigate. And it should include the untapped potential of patient reporting. These things, together with the hindsight of looking back at cases together are needed to identify diagnostic errors and give people and institutions the feedback on performance they need.”
“You really have to raise the consciousness of this,” Trowbridge concludes. ”Get the medical staff and administration to understand this is a big problem that has financial, clinical, quality, and patient satisfaction implications. That Mark [Graber] won the Eisenberg award is a sign that this isn’t going away. Be an early adopter, not a late one.”
For more information on this topic, contact Robert Trowbridge, MD, Director, Division of General Internal Medicine, Maine Medical Center, Portland, ME. Email: TROWBR@mmc.org