Diagnosis errors are a system problem, not just doctor’s fault
Executive Summary
The Institute of Medicine has issued a report calling on the medical community to more effectively address diagnostic errors. Reducing these errors will require a collaborative approach.
- Diagnostic errors are not typically caused by only a physician’s error.
- Radiologists and pathologists should be more involved with diagnoses.
- Risk managers should treat diagnostic errors as a system problem.
Diagnostic errors should be addressed as systemic problems and not human errors made by individuals, according to a recent report from the Institute of Medicine.
IOM called on the healthcare community to address diagnosis errors with a collaborative approach. IOM’s Report of the Committee on Diagnostic Error in Health Care outlines the steps necessary for reducing these errors. Committee Chair John R. Ball, MD, JD, said that although it has been estimated every American will suffer a consequential diagnosis error in his or her lifetime, no reliable figures exist for how many occur each year.
The key finding in the report is that reducing diagnosis errors will require a collaborative effort among not just healthcare team members, but also the patient and family, he said. (The IOM report is available online at http://tinyurl.com/oogmdas.)
“The stereotype of a single physician contemplating a patient’s presentation and discerning the diagnosis is not always true,” Ball said. “The diagnostic process often involves intra- and inter-professional teamwork. Nor is diagnostic error always due to human error. It often occurs because of errors in the healthcare system.”
The committee defines diagnostic error as “the failure to (a) establish an accurate and timely explanation of the patient’s health problem(s) or (b) communicate that explanation to the patient.” Despite the pervasiveness of diagnostic errors and the risk for serious patient harm, “diagnostic errors have been largely unappreciated within the quality and patient safety movements in healthcare,” the report says.
It goes on to say that, “Without a dedicated focus on improving diagnoses, these errors will likely worsen as the delivery of healthcare and the diagnostic process continue to increase in complexity.”
The IOM report stops short of calling for mandatory reporting of diagnosis errors but emphasizes that healthcare providers must improve the entire diagnostic process, not just reduce errors.
While acknowledging the pervasiveness of diagnostic errors, Ball warned against calls for mandatory public reporting.
“The committee believed that, given the lack of an agreement on what constitutes a diagnostic error, the paucity of hard data, and the lack of valid measurement approaches, the time was simply not ripe to call for mandatory reporting,” Ball said. “Instead, it is appropriate at this time to leverage the intrinsic motivation of healthcare professionals to improve diagnostic performance and to treat diagnostic error as a key component of quality improvement efforts by healthcare organizations. Better identification, analysis, and implementation of approaches to improve diagnosis and reduce diagnostic error are needed throughout all settings of care.”
Healthcare IT should be utilized more for diagnoses and not just billing or other administrative purposes, the report says. The IOM committee also calls for more involvement by radiologists and pathologists as members of the diagnosis team, and it praises the educational efforts of some medical malpractice insurers.
The report comes nearly 16 years after IOM’s landmark study To Err Is Human: Building a Safer Health System, which prompted a campaign to reduce medical errors.
The report outlines eight goals for improving diagnoses.
The Society to Improve Diagnosis in Medicine (SIDM) praised the report. Mark Graber, MD, founder and president of SIDM, a member of the report committee, says the report is a major milestone in the effort to improve diagnoses, quality of care and patient outcomes.
“Diagnosis is one of the most difficult and complex tasks in healthcare. There are more than 10,000 potential diagnoses, thousands of lab tests, and the problem that symptoms of each diagnosis vary from person to person,” he says. “Moreover, our healthcare systems are highly complex, which contributes to problems coordinating care and completing the diagnostic process successfully.”
SIDM recently spearheaded the launch of the Coalition to Improve Diagnosis, made up of leading healthcare organizations, to bring awareness, attention, and action to diagnostic error. Paul Epner, executive vice president of SIDM and chair of the Coalition, notes that diagnostic errors have no single root cause.
“This report addresses a significant gap in our knowledge, and SIDM intends to drive review and action on the recommendations across the entire healthcare system. It is the responsibility of everyone involved in the diagnostic process to consider the steps they can take to improve outcomes,” Epner says. “This begins with healthcare providers and their organizations, which need to establish a culture of safety where these errors can be identified, studied, and addressed.”
Diagnostic errors should be addressed as systemic problems and not human errors made by individuals, according to a recent report from the Institute of Medicine.
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