Scary Numbers and Sobering Questions about Diagnostic Errors

In an insightful piece published recently in the Journal of the American Medical Association (JAMA), three physicians ponder why errors in diagnosis are not represented in efforts to improve the quality of medical care and, ultimately, patient safety.

According to the authors, 40,000-80,000 people die every year from diagnostic errors; those are defined as mistakes due to delayed diagnosis, missed diagnosis and/or incorrect diagnosis. They represent from 10 to 20 out of 100 cases. They might be the result of incorrectly interpreting test results, “system-related” errors within a health-care organization or faulty clinical reasoning. Everyone makes mistakes, and the health-care profession is no different.

As the authors point out, most diagnostic errors cause little or no patient harm, or are discovered in time to fix them. Still, they’re largely preventable-the authors cite a recent survey of more than 6,000 doctors, and more than 9 in 10 said so.

One piece of the Affordable Care Act (ACA, the health-care reform act of 2010, or “Obamacare”) established the National Quality Strategy to “improve the delivery of health care services, patient health outcomes and population health.”

A primary goal of the strategy is to measure quality so that everyone-providers, patients, insurers-understands the standards, and, therefore, how to reach and maintain them across all aspects of care. Basically, it has three factors:

  • Better Care: Improve the overall quality of care, by making health care more patient-centered, reliable, accessible and safe.
  • Healthy People and Communities: Improve the health of the U.S. population by supporting proven interventions to address behavioral, social and environmental determinants of health in addition to delivering higher-quality care.
  • Affordable Care: Reduce the cost of quality health care for individuals, families, employers, and government.

The JAMA authors want to know “How is it … that improving diagnosis goes largely unrepresented in the current quality framework? The recently proposed National Quality Strategy focuses almost exclusively on management …” Diagnosis, they say, is overlooked in most efforts to ensure quality and safety.

Even the venerable report “To Err Is Human,” published in 1999 by the Institute of Medicine (IOM,), which we discussed in a recent post about medical error reporting, gives diagnostic mistakes short shrift. As the JAMA article notes, it mentions “medication error” 70 times, but “diagnostic error” only twice.

The JAMA authors attribute this lack of attention to a couple of things: difficulty understanding and measuring diagnostic errors; the “absence of ownership,” or the habit of medical providers not acknowledging and/or taking responsibility for mistakes. “Through malpractice suits,” they write, “physicians are well aware of diagnostic error, but there is a general tendency to perceive that such errors are made by someone else, someone less careful or skillful.”

And because certain other kinds of errors are clear-operating on the wrong body part, giving someone the wrong dose of medicine-diagnostic errors “seem intensely personal: the ‘system’ appears to be the physician, and his or her own knowledge, skills, values, and behaviors.”

But excluding these mistakes from an overall “diagnosis” of quality care has consequences the authors show can undermine patient safety. It breeds apathy within health care-organizations.

“We are unaware of any health care organization,” they write, “that is currently collecting specific data on diagnostic error or engaged in a system-wide campaign to decrease the frequency or consequences of diagnostic error.”

If you don’t have that information, they say, you can’t improve the ability to diagnose nor can you measure such progress.

They also show the relationship between diagnostic ability and the cost of care. We’ve written repeatedly about the health-care industry’s penchant for testing, testing, testing, and the consequences of such overtreatment. The JAMA article notes that costs related to such testing are “increasing faster than any other component of health care expenditures,” and acknowledges the harm it can cause when it’s wrong.

In summary, the writers call for an equal appreciation of diagnosis and treatment when it comes to defining a high quality of care. They call for medical schools to emphasize the importance of diagnosis, and teach students about the nature of human error, and how people progress from novice to expert. They call for the use of diagnostic checklists to guide clinicians toward systematic ways of diagnosing.

“For high-quality care,” they conclude, “being ‘well calibrated’-which includes physicians knowing their limits and accurately assessing their own degree of certainty with a diagnosis-may be just as important as being right.”

Medical training must be supported by policy. Oversight agencies and professional associations, the writers say, must include evaluations focused on diagnosis, establish standard standards for efficient workup of diseases, help define acceptable error rates and evaluate prevention strategies.

We all understand how “the thigh bone’s connected to the hip bone;” we need to understand how the diagnosis bone is connected to the treatment bone. To mix a metaphor…

Patrick Malone & Associates, P.C. listed in Best Lawyers Rated by Super Lawyers Patrick A. Malone
Washingtonian Top Lawyer 2011
Avvo Rating 10.0 Superb Top Attorney Best Lawyers Firm
Contact Information