Tuesday, September 22, 2015

Wrong diagnosis

Most Americans who go to the doctor will get a diagnosis that is wrong or late at least once in their lives, sometimes with terrible consequences, according to report released Tuesday by an independent panel of medical experts.

This critical type of health-care error is far more common than medication mistakes or surgery on the wrong patient or body part. But until now, diagnostic errors have been a relatively understudied and unmeasured area of patient safety. Much of patient safety is focused on errors in hospitals, not mistakes in diagnoses that take place in doctors’ offices, surgical centers and other outpatient facilities.

The new report by the Institute of Medicine, the health arm of the National Academy of Sciences, outlines a system-wide problem that experts say affects an estimated 12 million adults each year.

"Diagnostic errors are a significant contributor to patient harm that has received far too little attention until now," said Victor Dzau, institute president, in a statement...

Diagnostic errors result from a variety of causes, the committee found. They include inadequate collaboration among clinicians, patients and their families; limited feedback to clinicians about the accuracy of their diagnoses; and a health-care culture that discourages transparency and disclosure of errors.

One example cited in the report was about a woman, identified only as Carolyn, who arrived in the emergency room with chest pain and other classic symptoms of a heart attack. But her tests were normal, and the clinician told her she had acid reflux. A nurse even told her to stop asking questions of the doctor.

The woman was released a few hours later, feeling embarrassed about making a fuss. But over the next two weeks, she became sicker. She returned to the emergency department and clinicians told her she had had a heart attack caused by a blocked artery.

The report also said that health information technology may be contributing to diagnostic errors...

 Doctors often don’t know when they have made the wrong diagnosis, said Tejal Gandhi, president of the National Patient Safety Foundation, and an internal medicine doctor for 15 years. Often the scenario involves a physician missing something and a patient, who doesn't get better, seeking a second opinion. Something that was missed is picked up, and the first doctor never hears about it, said Kavita Patel, a healthy policy expert at the Brookings Institution's Center for Health Policy and a practicing primary care doctor at Johns Hopkins Medicine.

The report said health-care organizations need to put systems in place to identify diagnostic errors and near misses. They also need to adopt a non-punitive culture so open discussion and feedback can take place. That could be empowering for frontline workers like medical assistants to act as a check and balance, looking for gaps and raising flags, even if it's "something doctors won't like but will appreciate when they avoid a near miss," she said.



  1. The Institute of Medicine on Tuesday released a ground-breaking report calling wrong or delayed diagnoses a vast "blind-spot" in U.S. healthcare and blaming them for harming countless patients each year.

    The report, called "Improving Diagnosis in Health Care," asserts that diagnostic errors occur daily in every health care setting nationwide, yet they have never been adequately studied. No one knows how many people suffer from misdiagnoses or delays that affect their care.

    Despite the sketchy evidence, the authors conclude that "most people will experience at least one diagnostic error in their lifetime, sometimes with devastating consequences."

    "This problem is significant and serious [yet] we don't know for sure how often it occurs, how serious it is or how much it costs," says Dr. John Ball, of the American College of Physicians, who chaired the committee that carried out the analysis. He called the lack of evidence one of the committee's most "surprising" and distressing findings.

    Advocates hailed the report for calling attention to a problem that has been neglected for decades despite its importance to doctors and patients alike.

    "It's huge that diagnosis is finally getting the attention it deserves," says Helen Haskell, co-chair of the patient committee at the Society to Improve Diagnosis in Medicine, who was invited by the committee to review a draft of the report. "There are lots of people who think our failure to tackle this is one reason why patient safety hasn't progressed farther...

    Despite the committee's inability to offer even a rough estimate of the pervasiveness of faulty diagnoses--a limitation likely to disappoint patient advocates and others who were anticipating the committee's answer to that question--the report does offer some indications of the problem's seriousness.

    Studies show:
    • About 5 percent of adults who seek outpatient care annually suffer a delayed or wrong diagnosis.
    • Postmortem research suggests that diagnostic errors are implicated in one of every 10 patient deaths. Not every death is scrutinized, however, so the findings can't be generalized to all hospital patients.
    • Chart reviews indicate that diagnostic errors account for up to 17 percent of hospital adverse events.
    • Diagnostic errors are the principle cause of paid malpractice claims and are almost twice as likely to end in a patient's death than claims for other medical mishaps. They also represent the biggest share of total payments...(continued)

  2. (continued) Often diagnostic errors result from poor coordination of care. "Not all errors are individual human errors," he says. "They occur in a system that leads you into [certain] kinds of errors." He cited the emergency room, a chaotic setting with a constant stream of patients and information, where doctors, nurses, technicians and laboratory personnel must multi-task amid countless distractions...

    The glut of tests--some ordered by doctors who are practicing defensive medicine to protect against malpractice lawsuits--compounds the problem. "There's a tremendous reliance on tests," says Haskell, of the Society to Improve Diagnosis in Medicine. "You have to know to order the right test, and the test has to be interpreted correctly all along the line. It's a complicated system with a lot of opportunities for error."

    Clumsy health information technology, including electronic medical records, also represents a "barrier to good health care," Ball says, because information isn't easily accessible and is often presented in a confusing manner.

    Berwick, who also reviewed the report for the institute, cited one crucial omission--the committee decided not to address over-diagnosis, a diagnosis that is made that is not helpful to patients. "They might not define that as an error," he says, "But I think the task of addressing over-diagnosis is critical."

    Courtesy of: http://www.medpagetoday.com/PublicHealthPolicy/MedicalEducation/53702?isalert=1&uun=g906366d4541R5793688u&xid=NL_breakingnews_2015-09-24