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National Panel Makes Recommendations to Prevent Medical Diagnostic Errors


(SALT LAKE CITY)—It's unknown how many errors are made diagnosing medical diseases and conditions each year, but research has shown that such mistakes contribute to approximately 10 percent of patient deaths and account for 6 percent to 17 percent of adverse hospital events, according to a report from the National Academy of Sciences, Engineering, and Medicine (formerly the Institute of Medicine).

Diagnostic errors occur often enough that just about everyone receiving medical care will be misdiagnosed at some point. Some of those errors–which the report defines as an inaccurate or delayed diagnosis and the failure to communicate that to the patient–will be minor; others errors will be life threatening and cause irreversible damage. For example, a video accompanying the report tells the story of a woman whose heart attack was misdiagnosed as acid reflux. The video also describes the story of a man who now lives with cerebral palsy because his jaundice went untreated as a newborn despite pleas by his parents for treatment.

The problem with misdiagnoses such as these is likely to get worse unless the health care profession makes urgent changes, according to the report, called "Improving Diagnosis in Health Care."

A nationwide panel comprising 21 physicians and researchers studied the issue of diagnostic errors and issued the report, with eight multifaceted recommendations to address the problem. Panel member Michael Cohen, M.D., professor of pathology at the University of Utah School of Medicine, says the first recommendation–facilitating effective teamwork among health care providers and patients and their families–is an essential part of the solution. Teamwork, though, depends on something that sounds obvious but doesn't always occur: providers communicating diagnoses to patients.

"Making the changes needed to eliminate diagnostic errors will be difficult and require a team effort," Cohen says. "The patient and his or her family are part of the team—and the patient is at the middle of it all."

While communication is something that providers can and must address themselves, other problems leading to diagnostic errors are systemic, according to Cohen. The panel recommended tackling those issues in several ways, including:

  • Developing a culture in which providers can disclose and learn from diagnostic errors without a punitive climate
  • Establishing a work system that supports the diagnostic process and improvements in diagnostic performance
  • Developing and deploying approaches to identify, learn from and reduce diagnostic errors and near misses in clinical practice
  • Develop a reporting environment and medical liability system that facilitates improved diagnosis by learning from diagnostic errors and near misses
  • Designing a payment and care delivery environment that supports the diagnostic process

One reason it's hard to know how many diagnostic errors occur is that providers are reluctant to report them for fear of liability. That's why it's important to encourage transparency by addressing the medical liability system and creating an environment that gives providers the incentive voluntarily report diagnostic errors. "If you have a way of reporting these in an open way, we could all learn from these mistakes," Cohen says. "If you try to hide them, no one learns from them."

In addition to systemic changes, the panel made two other recommendations: enhancing the way health care professionals are trained in patient diagnosis and ensuring that health information technologies support patients and providers in the diagnostic process.

The University of Utah is addressing the education component by providing multidisciplinary training in which students all health sciences students–future nurses, pharmacists, therapists and physicians–train together not only to enhance teamwork but to learn the diagnostic process. The report particularly cites nurses as potentially having a larger role in that process.

Cohen cited access to electronic medical records (EMRs) as an example of how health information technologies could better support the diagnostic process. If someone goes to an emergency room, for example, having access to the patient's EMR can aid a physician in diagnosing the problem. Currently, however, EMRs are proprietary to individual health care systems, meaning providers who aren't part of a patient's network can't access their records. But having technology that would allow that access could improve the accuracy of a diagnosis in an emergency situation, Cohen says.

"Improving Diagnosis in Health Care" is the continuation of earlier Institute of Medicine reports including "To Err Is Human: Building a Safer Health System," "Crossing the Quality Chasm: A New Health System for the 21st Century" and "Preventing Medication Errors"–that also examined health care issues.

The current study was sponsored by the Agency for Healthcare Research and Quality, Centers for Disease Control and Prevention, American College of Radiology, American Society for Clinical Pathology, Cautious Patient Foundation, College of American Pathologists, The Doctors Company Foundation, Janet and Barry Lang, Kaiser Permanente National Community Benefit Fund at the East Bay Community Foundation, and Robert Wood Johnson Foundation.

With its report finished, Cohen says the committee now hopes the sponsoring organizations and other health care groups and the public will follow up on it. "We hope they'll become sufficiently interested to bring it to attention and lead to change."