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 typically are not caused only by a physician’s error.
- Radiologists and pathologists should be more involved with diagnoses.
- Risk managers should treat diagnostic errors as a system problem.
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Diagnostic errors are underappreciated and will require a collaborative approach to reduce them, according to a recent report from the Institute of Medicine (IOM).
IOM called on the healthcare community to address diagnosis errors by treating them as systemic problems and not human errors made by individuals. IOM’s Improving Diagnosis in Health Care report outlines the steps necessary for reducing these errors. Although it has been estimated all Americans will suffer consequential diagnosis errors in their lifetimes, no reliable figures exist for how many occur each year, said John R. Ball, MD, JD, of Asheville, NC, chair of the Committee on Diagnostic Error in Health Care. The key report finding 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. “Without a dedicated focus on improving diagnoses, these errors likely will 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 it 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 used more for diagnoses and not just billing or other administrative purposes, the report says. The report also calls for more involvement by radiologists and pathologists as members of the diagnostic 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. (See the story on those goals in this issue.)
Problems related to diagnostic error are the most common allegation in medical malpractice claims, says Medical Director David B. Troxel, MD, of The Doctors Company, a malpractice insurance provider in Napa, CA.
“We agree with the recommen-dation in this new report that medical liability insurers collaborate with healthcare professionals on opportunities to improve diagnostic performance,” Troxel says. He notes that The Doctors Company has the largest single database of diagnosis-related medical malpractice claims and shared claims data on diagnostic error with the IOM. The Doctors Company Foundation also provided funding for the report.
The report is a major milestone in the effort to improve diagnoses, quality of care, and patient outcomes, says Mark Graber, MD, founder and president of The Society to Improve Diagnosis in Medicine (SIDM), a member of the report committee.
“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.”
Diagnostic errors have no single root cause, says Paul Epner, executive vice president of SIDM and chair of the Coalition to Improve Diagnosis. SIDM recently spearheaded the launch of the Coalition to bring action to diagnostic errors.
“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.”
•David B. Troxel, MD, Medical Director, The Doctors Company, Napa, CA. Email: [email protected].
