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Wachter urges focus on reduction of diagnostic errors

Robert Wachter Wachter
At the sixth International Conference on Diagnostic Error in Medicine on Wednesday, Dr. Robert Wachter gave a quick history of patient safety and quality improvement but noted that activity to reduce diagnostic errors was noticeably absent from the movements' timeline.

“There's still not a lot of action promoting this agenda,” said Wachter, professor and associate chair of the Department of Medicine at the University of California at San Francisco. He made the remark after describing events that took place after the Institute of Medicine published “To Err is Human,” its report on medical errors, in 1999.

Diagnostic errors can result in delayed treatment, wrong treatment or ineffective treatment. A recent report in the Journal of Patient Safety calculated that the number of premature deaths caused by preventable harm to patients could be between 210,000 to 400,000 annually (a considerable increase from the 98,000 estimated in “To Err is Human”), and it cites a 2009 report that includes an estimate that 40,000 to 80,000 of U.S. hospital deaths are due to diagnostic error. In April, a study in the journal BMJ Quality and Safety calculated that 100,249 out of 350,706 medical malpractice claims filed in the National Practitioner Data Bank that led to payouts between 1986 and 2010 were diagnosis related.

Wachter, who spoke at the first conference on diagnostic error in medicine in 2008, noted that diagnostic errors are not on the Never Events list of medical mishaps that should never occur, there is no Joint Commission standard promoting better diagnosis, and there are no strategies to eliminate diagnostic errors in any of the federal government's public reporting programs.

He said there is now far more pressure on the delivery system to improve its performance, but none of that pressure is targeting diagnostic errors.

Wachter just recently finished a term as chairman of the American Board of Internal Medicine, and touted medical specialty boards developing “robust maintenance of certification” programs as a key to improving diagnostic skills and thinking. Instead of having to pass a one-time exam as in years past, Maintenance of Certification transformed specialty board certification into a continuous process where physicians continuously learn but also must continuously prove their competency.

He lamented the lack of “global trigger tools” in electronic health-record systems that could work to reduce diagnostic errors. While Wachter said early EHR studies may have oversold their effectiveness, he thinks future EHRs could produce better results—explaining that health information technology is actually getting better “but it feels like it's getting worse” because the state of IT in people's daily lives is becoming so advanced.

Low-tech interventions may hold the answer, he said. These include instilling a patient safety/quality improvement culture and promoting medical professionalism. “That has turned out to have a lot of oomph to it—more than I expected,” Wachter said. “Professionalism is a surprisingly powerful lever.”

It's unlikely a one-size–fits-all solution will emerge, which is why specialty-specific responses from medical boards are important, Wachter said, adding that those seeking a national policy should “be careful what you wish for.”

“What should we do? I really don't know,” Wachter said. But before going to the CMS for an answer, he suggested advocates should engage specialty boards, the Joint Commission, the National Quality Forum, the Institute of Medicine, the National Patient Safety Foundation, the Institute for Healthcare Improvement and malpractice insurance carriers.

“CMS should be last, not first,” he said.

An audience member asked two speakers who followed Wachter, Dr. Mark Graber, senior scientist at RTI International, Research Triangle Park, N.C., and Dr. Gordon Schiff, with Brigham and Women's Hospital in Boston, why the public has been so quiet on this issue.

Schiff said the public is awakening to the problem, but added “It's up to us to put all that in gear.”

Graber, who is also president of the Society to Improve Diagnosis in Medicine, said there are a lot of good ideas, but still not a lot of good data and that advocates are going to have learn how to better measure the scope of the problem.

About 230 people attended the conference which was co-sponsored by the Society to Improve Diagnosis in Medicine and the Northwestern University Feinberg School of Medicine, which hosted the Sept. 22-25 event.

The event had an unconventional closing. Dr. George Lundberg, a former editor-in-chief of the Journal of the American Medical Association and president of the Lundberg Institute in Los Gatos, Calif., gave a critique of the conference in which no one was spared his wrath. He singled out a few creators of poster presentations for fine work, but gave one a “gold star” for best use of colors and “confusing arrows.”

Lundberg said a keynote speech by Dr. Brent James, chief quality officer and executive director of Intermountain Healthcare's Institute for Health Care Delivery Research in Salt Lake City, “was nice.” But then he criticized James for giving the same speech he's given numerous times without tailoring it to the agenda of the conference, and then ridiculed James' message that health IT will help improve safety and quality.

“I would say 'Hold your breath and pray a lot and maybe it will all come true,'” Lundberg said.

He said the opposite of Wachter, however. “What Bob did this morning was demonstrate why lecture will survive as a teaching tool,” Lundberg said. “The audience will leave understanding more than when they came in.”

But all the speakers were taken to task for not responding to an audience member's question early in the conference about the Journal of Patient Safety report with the new and higher calculation of deaths caused by medical error

“There was a question from the floor not answered in four days,” Lundberg said. “Somebody should have read that and came up with an insightful answer about whether it added to the literature or not.”

Lundberg, who was trained in pathology, offered his own suggestion for reducing diagnostic errors: Revive the practice of autopsies, which help doctors understand what they may have missed and why. “It's basically gone from hospitals,” he said. “Docs don't want to know.”

In answer to the question about why the public isn't more outraged over diagnostic errors, Lundberg said it was because people are being “fed a steady diet of hope and hype” by both the healthcare and pharmaceutical industries. But he unleashed extra scorn on drug industry “disease mongering” where he said, if a drug is invented, then they can find a disease for it—such as restless leg syndrome.

Next year's conference has been scheduled for Sept. 13-17 in Atlanta.

Follow Andis Robeznieks on Twitter: @MHARobeznieks


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