An unacceptable number of patients in their lifetime will experience a misdiagnosis or a delayed explanation of their illness, according to a highly anticipated new report on diagnostic mistakes.
The problem is a “blind spot” prevalent throughout all healthcare settings, one that can't simply be blamed on bad doctors, according to a report released Tuesday by the National Academies of Sciences, Engineering and Medicine titled Improving Diagnosis in Health Care.
The diagnostic process occurs within a work system and is not just the working of a single caregiver's mind, said Dr. John Ball, chair of the academies' committee on diagnostic error in healthcare.
The blind spot "occurs because of errors in the health care system,” he said. “Better identification, analysis, and implementation of approaches to improve diagnosis and reduce diagnostic error are needed throughout all settings of care.”
The report challenges the current thinking of how patients learn about a condition. The idea that a sole physician is responsible for relaying information is a “stereotype,” the authors state. The process involves teams of healthcare professionals, but also includes input from patients and their caregivers.
And human error is not always the culprit, the report says. Poorly utilized healthcare information technology, systems that rush the diagnostic process, and a lack of metrics to track incidents are other factors, according to the report.
The committee estimates about 5% of outpatients experience a diagnostic error each year, and that 1 out of 10 patient deaths from errors may be related to the diagnostic oversights.
It's the newest in a series of reports from the academies that focus on the road to healthcare quality, which is unfinished and rife with potholes. This report is a follow-up to the 1999 landmark To Err Is Human, which placed national focus on patient safety and led to sweeping U.S. policy changes.
To Err is Human galvanized safety work in the inpatient setting, but the issue of diagnostic mistakes extends those efforts to other healthcare settings, says Dr. Kedar Mate, senior vice president of the Institute for Healthcare Improvement.
“This problem really challenges us to pay attention to ambulatory and primary care,” he said. “People are finally aware that there are great risks when you go into a hospital, but I don't believe they are as conscious of the potential harms that can occur when they see their family practice doctor, pediatrician or internist.” Mate is not a member of the committee, but the IHI has been pushing for more focus on diagnostic issues.
A 21-member multidisciplinary committee of physicians, researchers, health policy and quality leaders at the Institute of Medicine met for over a year to evaluate existing data, get a sense of the burden of harm and costs associated with diagnostic mistakes and create national standards.
The report makes eight recommendations based on the current evidence. Providers are encouraged, for example, to facilitate more effective teamwork in the diagnostic process, which has been shown to reduce mistakes and boost clinician confidence.
The committee also recommends enhancing education and training in the diagnostic process. That would include educational approaches that update clinicians about new evidence-based guidelines, certification and accreditation programs that test competency and processes across healthcare professionals' career trajectory.
The report states that the stakes are too high to continue with the status quo.
Too often missed diagnoses are revealed when a patients files costly medical liability claims. The mean payout for a diagnosis error is $386,849, according to an estimate in the report. The committee recommends changes to the legal environment that would facilitate the timely identification, disclosure, and lesson from diagnostic errors.
The adoption of communication and resolution programs is encouraged as key to improving the process. Experts recently told Modern Healthcare that few hospitals have adopted such policies as they require a culture change that encourages doctors and hospital staff to speak up about potential issues without fear of punishment. Many organizations struggle to create that environment.
While the report marks a milestone in the attempt to address the complexity of diagnostics and its role in the uphill battle to improve quality , the new recommendations are just the beginning.
Making an accurate diagnosis involves clinical reasoning, it requires understanding the cognitive contributions that lead to decision-making, explained Dr. Tejal Gandhi, president and chief executive officer of the National Patient Safety Foundation. She was one of the experts chosen to do an independent review of the draft report before it was finalized.
“The cognitive aspect is a challenging area for us because there is a lot of judgment and hindsight bias,” Gandhi explained. “Once you know what the diagnosis is, it's pretty easy to say they should have seen it, but it's much different when you're in the middle of it.”
There also remains a lack of agreement on what constitutes a diagnostic error, a paucity of hard data, and solid ways to measure the scope of the problems. “The time was simply not ripe to call for mandatory reporting” to hold clinicians accountable for the mistakes, the report said.
The committee began its research in January 2014 and was sponsored by 10 organizations. They include the Agency for Healthcare Research and Quality; American College of Radiology; American Society for Clinical Pathology, Cautious Patient Foundation, Centers for Disease Control and Prevention, College of American Pathologists, The Doctors Company Foundation, Janet and Barry Lang, Kaiser Permanente National Community Benefit Fund; and the Robert Wood Johnson Foundation.
A next step will be to find ways to adapt the report's concepts within hospitals and health systems that currently do not have that infrastructure, says Dr. Hardeep Singh, a patient-safety researcher at the Michael E. DeBakey Veterans Affairs Medical Center in Houston, and a reviewer of the report.
“This is where the rubber meets the road,” he said. The report highlights key areas to begin improvement, but there are many interventions for diagnostic errors that have not been rigorously evaluated, he said.
“We need evidence to make sure the interventions are good (and) don't have unintended consequences,” Singh said.