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Diagnostic Errors: A 'Moral, Professional and Public Health Imperative'

Most patients will experience one or more diagnostic errors during their lifetime, causing potential harm from delayed or inappropriate treatments and tests. Diagnostic errors also can impact patients psychologically and financially.
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For years, patient safety efforts have focused on mistakes that occur during treatment, from medication errors to post-surgical complications. Since the Institute of Medicine (IOM) released the groundbreaking "To Err is Human" in 1999, clinicians and hospitals have made significant progress advancing patient safety.

Yet diagnostic errors have been largely overlooked. Consider the impact of a missed, wrong or delayed diagnosis, which in the U.S.:

 Affects 1 in 20 patients, or 12 million adults, in outpatient settings per year
 Accounts for 6-17 percent of adverse events in hospitals
 Contributes to 1 in 10 patient deaths

Most patients will experience one or more diagnostic errors during their lifetime, causing potential harm from delayed or inappropriate treatments and tests. Diagnostic errors also can impact patients psychologically and financially. And, they represent the largest fraction of U.S. malpractice claims and the highest total of penalty payouts -- totaling $38.8 billion between 1986 and 2010, according to research published in BMJ Quality & Safety.

In September, the IOM underscored the need for increased focus on diagnostic errors in "Improving Diagnosis in Health Care," calling improvements to the diagnostic process a "moral, professional and public health imperative."

Diagnostic errors are complicated, with uncertainty an "inherent element at every step of the diagnostic process," according to "Improving Diagnosis in Health Care -- The Next Imperative for Patient Safety," published online in The New England Journal of Medicine in November.

In contrast, mistakes that occur during treatment -- such as surgeries performed on the wrong side of the body -- are easier to identify and more obviously egregious. At the Midwest Alliance for Patient Safety (MAPS), we consider diagnostic errors an important part of our work to improve patient safety, and we're ready to help our members work through the challenges of reducing diagnostic errors.

The IOM identifies four reasons why diagnostic errors occur:

 Inadequate collaboration and communication among clinicians, patients and patients' families
 Health care system not designed to support the diagnostic process
 Limited feedback to clinicians about their performance diagnosing patients
 A culture that discourages reporting of diagnostic errors

These causes are both broad and specific. The patient safety community has advocated for better communication and collaboration for years -- with positive results. We simply need to refocus our attention to ensure that good communication and collaboration occur in the diagnostic process. Similarly, MAPS has long supported reporting adverse events without fear, and we encourage the reporting of diagnostic errors, as well. Addressing cultural and systematic issues will surely take time.

The IOM offers eight goals to reduce errors and improve diagnosis:

 Facilitate more effective teamwork in the diagnostic process among clinicians, patients and patients' families
 Enhance health care professional education and training in the diagnostic process
 Ensure that health information technologies support patients and clinicians in the diagnostic process
 Develop and deploy approaches to identify, learn from and reduce diagnostic errors in clinical practice
 Establish a work system and culture that supports the diagnostic process and improvements in diagnostic performance
 Develop a reporting environment and medical liability system that facilitates improved diagnosis through learning from diagnostic errors
 Design a payment and care delivery environment that supports the diagnostic process
 Provide dedicated funding for research on the diagnostic process and diagnostic errors

These goals are good starting points for conversations we'd like to have with our members. There is much to talk about and much at stake. As the IOM says, "improving diagnosis will require collaboration and a widespread commitment to change among health care professionals, health care organizations, patients and their families, researcher, and policy makers."

Reference:

1. https://iom.nationalacademies.org/~/media/Files/Report%20Files/1999/To-Err-is-Human/To%20Err%20is%20Human%201999%20%20report%20brief.pdf