According to a new study most people will experience at least one diagnostic error, such as an inaccurate or delayed diagnosis, in their lifetime. This is big news in the medical communities, as these errors can have devastating consequences. The report calls for urgent change to improve diagnosis in health care or says diagnostic errors will likely worsen.
A committee from the Institute of Medicine of the National Academies of Sciences, Engineering, and Medicine conducted the study and found that although getting the right diagnosis is a key aspect of health care, efforts to improve diagnosis and reduce diagnostic errors have been quite limited. That may be due to the fact that improving diagnosis is a complex challenge, partly because making a diagnosis requires collaboration and a number of different steps that all have potential for error.
To improve diagnosis, the committee called for “more effective teamwork among health care professionals, patients, and families; enhanced training for health care professionals; more emphasis on identifying and learning from diagnostic errors and near misses in clinical practice; a payment and care delivery environment that supports the diagnostic process; and a dedicated focus on new research.”
“These landmark IOM reports reverberated throughout the health care community and were the impetus for system-wide improvements in patient safety and quality care,” said Victor J. Dzau, president of the National Academy of Medicine. “But this latest report is a serious wake-up call that we still have a long way to go. Diagnostic errors are a significant contributor to patient harm that has received far too little attention until now. I am confident that Improving Diagnosis in Health Care, like the earlier reports in the IOM series, will have a profound effect not only on the way our health care system operates but also on the lives of patients.”
Causes of Errors
One of the problems is that data on diagnostic errors is sparse, due to the fact that few reliable measures exist, and errors are often found in retrospect. However, based on the limited evidence, the committee determined that diagnostic errors stem from a wide variety of causes that include:
- Inadequate collaboration and communication among clinicians, patients, and their families;
- A health care work system ill-designed to support the diagnostic process;
- Limited feedback to clinicians about the accuracy of diagnoses; and
- A culture that discourages transparency and disclosure of diagnostic errors, which impedes attempts to learn and improve.
As the delivery of health care and the diagnostic process continues to increase in complexity errors will likely worsen, the committee concluded.
In order to improves the process the committee called for a significant re-envisioning of the diagnostic process and a widespread commitment to change from a variety of stakeholders will be required.
John R. Ball, chair of the committee and executive vice president emeritus, American College of Physicians explains, ”Diagnosis is a collective effort that often involves a team of health care professionals — from primary care physicians, to nurses, to pathologists and radiologists. The stereotype of a single physician contemplating a patient case and discerning a diagnosis is not always accurate, and a diagnostic error is not always due to human error. Therefore, to make the changes necessary to reduce diagnostic errors in our health care system, we have to look more broadly at improving the entire process of how a diagnosis made.”
Patient Involvement Key
The report found patients and families are actually key to improving the process as they contribute valuable input that informs diagnosis and decisions about their care. In order to assist patients, the committee recommended that health care organizations and professionals provide them with more opportunities to learn about their diagnosis, as well as increased access to electronic health records, including clinical notes and test results. Also, health care organizations and professionals should ensure that they are creating an environment in which patients and families are comfortable sharing feedback and concerns about possible diagnostic errors. Often these concerns are muffled due to fear of lawsuits but if handled properly, they can help find errors.
To help patients receive a better diagnosis, the study encourages patients to be proactive in finding resources to ensure they effectively tell their story, be a good historian, keep good records, be an informed consumer, take charge of managing their health care, follow up with their clinicians, and encourage clinicians to think about other potential explanations for their illness.
While few health care organizations currently have processes in place to identify diagnostic errors the study found that collecting this information, learning from these experiences, and implementing changes are critical for improving the situation. As often the culture of health care organizations discourages identification and learning, the committee called for these institutions to promote a non-punitive culture that values open discussions and feedback on diagnostic performance.
On the legal side the report called for reforms to the medical liability system are needed to make health care safer by encouraging transparency and disclosure of diagnostic errors. States, in collaboration with other stakeholders, should promote a legal environment that facilitates the timely identification, disclosure, and learning from diagnostic errors. Voluntary reporting efforts should also be encouraged and evaluated for their effectiveness.
Payment and care delivery models also likely influence the diagnostic process and the occurrence of diagnostic errors, but information about their impact is limited and this is an important area for research, the committee said. It recommended changes to fee-for-service payment to improve collaboration and emphasize important tasks in the diagnostic process. For example, the Centers for Medicare & Medicaid Services and other payers should create codes and provide coverage for evaluation and management activities, such as time spent by pathologists and radiologists in advising treating physicians on testing for specific patients.
They also ask that payers reduce distortions in the fee schedule that place greater emphasis on procedure-oriented care than on cognitive-oriented care, because they may be diverting attention from important tasks in diagnosis, such as preforming a thorough clinical history, interview, and physical exam, or decision making in the diagnostic process.
Additionally, the committee recommended that health care professional education and training emphasize clinical reasoning, teamwork, communication, and diagnostic testing. The committee also urged better alignment of health information technology with the diagnostic process. Furthermore, federal agencies should develop a coordinated research agenda on the diagnostic process and diagnostic errors by the end of 2016. This report is a continuation of the Institute of Medicine’s Quality Chasm Series, which includes reports such as “To Err Is Human: Building a Safer Health System,” and “Crossing the Quality Chasm: A New Health System for the 21st Century, and Preventing Medication Errors.”
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