Sixteen years after its heralded “To Err Is Human: Building a Safer Health System”1 report, which precipitated a continuing push for improvements in safety and quality, the Institute of Medicine (IOM) is now taking direct aim at diagnostic errors. In a new 369-page report, “Improving Diagnosis in Health Care,” the authors conclude that while most people will likely experience a significant diagnostic error in their lifetime, the importance of this problem is under-appreciated.
Specifically, the report suggests that according to conservative estimates, 5% of adults who seek outpatient care each year experience a diagnostic error, and that research over many decades shows that diagnostic errors contribute to roughly 10% of all deaths. The authors also note that medical record reviews indicate that diagnostic errors cause 6% to 17% of hospital adverse events. They further point out that diagnostic errors are a key driver of medical malpractice claims. In short, the IOM report states that diagnostic errors continue to occur in all types of care settings, and that they cause harm to an unacceptably high number of patients.2
It’s an issue that is of particular concern to emergency physicians (EPs), many of whom make scores of diagnoses every week, often under pressure and extremely stressful circumstances. While arriving at a correct diagnosis in the emergency setting can often be challenging, emergency medicine leaders seem ready to embrace a number of the sweeping recommendations for improvement made in the IOM report.
Tort reform is key
Michael Gerardi, MD, FAAP, FACEP, president of the American College of Emergency Physicians, praises the investigators involved in the IOM report, and suggests EPs are likely to support the findings.
“This is not the real, definitive plan, but [the report] does a good job of highlighting what the problem areas are to try to get to the bottom of this and come to some solutions,” he explains. “We should think about this a lot ... one of our biggest risks as EPs is diagnostic error.”
Of particular interest to Gerardi is the report’s call for changes to the reporting environment and medical liability system so that healthcare professionals are encouraged to identify and report diagnostic errors and near misses. This is closely related to another recommendation in the report that calls on healthcare organizations to establish a culture that supports improvements in the diagnostic process, including policies and practices that encourage a non-punitive environment for reporting errors.
“I am all for transparency and exposing the problems in making an accurate diagnosis if there is protection for highlighting and researching this area,” Gerardi says. “Right now, if you admit to making a mistake regarding safety or quality, and if it is not in a tightly controlled hospital peer-review, it is discoverable. People keep things very contained and are hesitant to share.”
Gerardi notes that litigation is a constant threat, even when EPs closely adhere to the recommendations of national guidelines.
“There are always doubters who say [the guidelines] are not 100% reliable and that you should use your own clinical judgement,” he says. “There are all these countervailing forces. [People] want us to decrease testing and follow guidelines and pathways, and yet there are no protections if we do.”
Improve HIT, teamwork
Another recommendation suggests ensuring that health information technology (HIT) supports both patients and providers in the diagnostic process. On this point, Gerardi is particularly keen on interoperability and the importance of being able to access patient medical records.
“When you have a good central repository for records, and/or physicians who know the patient, it makes it so much safer to have follow-up so that [these physicians] can continue the workup, and not try to come up with the diagnosis in the ED all the time,” Gerardi explains. “Health information exchanges [HIE] are going to help improve that. In some environments where I have worked, I was able to bring up every CT a patient had within 50 square miles.”
However, when such records are not readily available, and a primary care physician (PCP) is not accessible, the EP is sometimes unfairly blamed for initiating an expensive workup, Gerardi notes.
This point also relates to teamwork, the focus of another recommendation from the IOM report. The authors state that more steps should be taken to facilitate inter-professional and intra-professional teamwork throughout the diagnostic process. The recommendation refers to collaboration among pathologists, radiologists, and other healthcare professionals. It also stresses that patients and families should be included in the diagnostic process.
“I find it very hard to get someone’s PCP to call me during the time when people tend to present [to the ED], which is after [normal business office] hours,” notes Gerardi, adding that he hears similar complaints from the accountable care organization (ACO) that operates in his region. “The ACO laments about the fact that they don’t get notified when their patient was [in the ED].”
Part of the problem is that some electronic medical record (EMR) systems are not robust enough to communicate with other systems, but that isn’t the only issue.
“A lot of physicians are hesitant to get on their computers and log into a hospital portal for labs and [other information] on patients who have been there,” Gerardi notes. “There is a lag in the culture.”
Institute feedback mechanisms
The IOM report calls for improvements in professional education in the diagnostic process, noting that training should be based on evidence and cover such topics as the appropriate use of testing and HIT, teamwork, communications, and clinical reasoning. The report also calls on professional organizations to ensure clinicians maintain competency in these areas.
Gerardi agrees that these elements should be a focal point for future improvements, but he also points to the ACEP’s expert panel on Ebola as one way the emergency profession is stepping up efforts to ensure that frontline clinicians quickly receive the information and education they need to make accurate diagnoses.
“The panel can stand up within hours and start preparing [information] for physicians,” he explains.
It’s an example of the type of professional collaboration that will help to prevent missteps like those that occurred last year when a patient with Ebola was misdiagnosed on his first trip to a Dallas ED, touching off a nationwide crisis, Gerardi explains. He adds that the ACEP and the CDC have collaborated in similar fashion to address measles outbreaks and other infectious threats.
In another recommendation, the IOM report calls for developing approaches to identify and learn from diagnostic errors. The authors say this requires action on several fronts, from accreditation organizations to government agencies and providers themselves. Such efforts should include methods for monitoring the diagnostic process and mechanisms for providing feedback on diagnostic performance to individual providers, as well as care teams and clinical leaders.
Robert Trowbridge, MD, FACP, the division director of General Internal Medicine at Maine Medical Center in Portland, ME, is pleased to see this recommendation, as he provided input to the investigators preparing the IOM report.
“As it stands right now, we tend not to use identified errors as a means of personal and institutional improvement, and that needs to change,” he says. “We need to have systemic and rigorous means of identifying errors on multiple levels and, just as importantly, have a means of responding to those errors.” (See below: “Consider environment, context when seeking to reduce diagnostic errors.”)
Trowbridge adds that clinicians often do not hear about when they made a decision that resulted in a bad outcome, much less when they made a decision that resulted in a good outcome. This is certainly the case for EPs, as they do not often see or hear from their patients after they have been discharged from the ED.
“We need to have all sorts of feedback on our diagnostic performance, good and bad, if we’re going to improve as individual clinicians,” he explains. “We need to have learning clinicians within learning institutions within a learning healthcare system. Feedback on performance is key to achieving this.”
Take action to improve
Other recommendations in the IOM report call for changes to the payment and care delivery environment so that needed tests and evaluations are fully covered. Additionally, the report also calls for more dedicated funding specifically for research pertaining to diagnostic errors.
Gerardi acknowledges that all the recommendations outlined in the IOM report involve big, systemic changes that will be difficult to implement, but he reiterates that they represent steps that EPs can get behind.
“The [ACEP] supports this because we can have an open discussion now about what is a good way to approach diagnosis, and what is an acceptable error rate and what is not,” he explains. “I would like to see an open debate.”
Trowbridge suggests that the IOM did a good job of tackling a very difficult issue, and he is hopeful that providers, policy-makers, and other stakeholders will move without delay to implement many of the report’s recommendations.
“There really is no excuse for an institution not to immediately examine what it has been doing in terms of diagnostic error and what it needs to do now,” he says. “As the IOM points out, nearly every American at some point in his or her life will be subject to a diagnostic error. You can’t say that about many other patient safety issues.”
Kohn L, et al. To Err Is Human: Building a Safer Health System. National Academies Press 2000. https://iom.nationalacademies.org/Reports/1999/To-Err-is-Human-Building-A-Safer-Health-System.aspx.
Balogh E, et al. Improving Diagnosis in Health Care. National Academies Press 2015. http://iom.nationalacademies.org/reports/2015/improving-diagnosis-in-healthcare.
Michael Gerardi, MD, FAAP, FACEP, Immediate Past President, American College of Emergency Physicians; Attending Physician and Faculty, Department of Emergency Medicine, Morristown Memorial Medical Center in Morristown, NJ; and Senior Vice President for Emergency Medical Associates, a Parsippany, NJ-based emergency physician practice management group. E-mail: [email protected]
Robert Trowbridge, MD, FACP, Division Director, General Internal Medicine, Maine Medical Center, Portland, ME, and Assistant Professor of Medicine, Tufts University School of Medicine, Boston. E-mail: [email protected]
Consider Environment, Context When Reducing Diagnostic Errors
In developing ways to reduce diagnostic errors, it is important for emergency physicians to consider not just their thought process or skill level, but also the impact of contextual factors, observes Robert Trowbridge, MD, FACP.
“Recently, we’ve come to recognize the importance of context on diagnostic reasoning, not just the content of a particular encounter, but also factors specific to the patient and the environment,” he explains.
For example, whether the ED is busy or quiet, crowded or empty, or whether it is day or night are all factors that can impact diagnostic reasoning, notes Trowbridge, who has performed extensive research on the factors that contribute to diagnostic errors.1,2
“What we may do with a specific patient may vary greatly depending on the environment we’re in, even if the patient presentation is absolutely identical,” he says. “We need to be cognizant of these contextual factors when we’re looking at the decisions we make and the outcomes we have.”
Trowbridge notes that the way a patient makes a clinician feel can impact the diagnosis process.
“We like some patients and don’t like other patients, and this affects our thinking,” he says. “We may have a difficult time admitting or acknowledging this, but it really can have a significant effect. In addition, clinician fatigue, burn-out, emotional state, and a whole host of other physician-based factors can have an impact on our thinking in an individual situation.”
What can healthcare leaders and administrators do to ensure that such factors do not negatively impact diagnostic accuracy? Trowbridge states that they need to support clinicians.
“Ensure they have adequate time, space, and support to do the work they need to do,” he says. “Ensure there is adequate back-up when times are busy [and] build a culture that not only condones, but promotes asking for help.”
Graber ML, et al. The next organizational challenge: Finding and addressing diagnostic error. Jt Comm J Qual Patient Saf 2014;40:102-110.
Trowbridge R, et al. Educational agenda for diagnostic error reduction. BMJ Qual Saf 2013; suppl 2:ii28-ii32.