Executive Summary

Emergency medicine leaders welcome a major new report from the Institute of Medicine (IOM) calling on providers, policy makers, and government agencies to institute changes to reduce the incidence of diagnostic errors. The 369-page report, “Improving Diagnosis in Health Care,” states that the rate of diagnostic errors in this country is unacceptably high and offers a long list of recommendations aimed at addressing the problem. These include large, systemic changes that involve improvements in multiple areas, including health information technology (HIT), professional education, teamwork, and payment reform. Further, of particular interest to emergency physicians are recommended changes to the liability system.

  • The authors of the IOM report state that while most people will likely experience a significant diagnostic error in their lifetime, the importance of this problem is under-appreciated.
  • According to conservative estimates, the report says 5% of adults who seek outpatient care each year experience a diagnostic error. The report also notes that research over many decades shows diagnostic errors contribute to roughly 10% of all deaths.
  • The report says more steps need to be taken to facilitate inter-professional and intra-professional teamwork throughout the diagnostic process.
  • Experts concur with the report’s finding that mechanisms need to be developed so that providers receive ongoing feedback on their diagnostic performance.

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.”

REFERENCES

  1. Graber ML, et al. The next organizational challenge: Finding and addressing diagnostic error. Jt Comm J Qual Patient Saf 2014;40:102-110.
  2. Trowbridge R, et al. Educational agenda for diagnostic error reduction. BMJ Qual Saf 2013; suppl 2:ii28-ii32.