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Taking Steps Towards a Safer Future: Measures to Promote Timely and Accurate Medical Diagnosis

  • Mark L. Graber
    Correspondence
    Requests for reprints should be addressed to Mark Graber, MD, Medical Service–III, Veterans Affairs Medical Center, Northport, New York 11768.
    Affiliations
    Veterans Affairs Medical Center, Northport, New York, and Department of Medicine, State University of New York at Stony Brook,Stony Brook, New York, USA
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      The issue of diagnostic error is just emerging as a major problem in regard to patient safety, although diagnostic errors have existed since the beginnings of medicine, millennia ago. From the historical perspective, there is substantial good news: medical diagnosis is more accurate and timely than ever. Advances in the medical sciences enable us to recognize and diagnose new diseases. Innovation in the imaging and laboratory sciences provides reliable new tests to identify these entities and distinguish one from another. New technology gives us the power to find and use information for the good of the patient. It is perfectly appropriate to marvel at these accomplishments and be thankful for the miracles of medical science.
      It is equally appropriate, however, to take a step back and consider whether we are really where we would like to be in regard to medical diagnosis. There has never been an organized discussion of what the goal should be in terms of diagnostic accuracy or timeliness and no established process is in place to track how medicine performs in this regard. In the history of medicine, progress toward improving medical diagnosis seems to have been mostly a passive haphazard affair.
      The time has come to address these issues. Every day and in every country, patients are diagnosed with conditions they don't have or their true condition is missed. Furthermore, patients are subjected to tests they don't need; alternatively, tests they do need are not ordered or their test reports are lost. Despite our best intentions to make diagnosis accurate and timely, we don't always succeed.
      Our medical profession needs to consider how we can improve the accuracy and timeliness of diagnosis. Goals should be set, performance should be monitored, and progress expected. But where and how should this process be started? The authors in this supplement to The American Journal of Medicine focus on the physician's role in diagnostic error; a variety of strategies are offered to improve diagnostic calibration and reduce diagnostic errors. Although many of these strategies show potential, the pathway to accomplish their goals is not clear. In some areas, little research has been done while in others the results are mixed. We don't have easy ways to track diagnostic errors; no organizations are ready or interested to compile the data even if we did. Moreover, we are uncertain how to spark improvements and align motivations to ensure progress. Although our review
      • Berner E.
      • Graber M.L.
      Overconfidence as a cause of diagnostic error in medicine.
      focuses on overconfidence as a pivotal issue in an effort to engage providers to participate in error-reducing strategies, this is just one suggestion among many; a host of other factors, both cognitive and system related, contribute to diagnostic errors.
      For all of these reasons, a broader horizon is appropriate to address diagnostic error. My goal in this commentary is to survey a range of approaches with the hope of stimulating discussion about their feasibility and likelihood of success. This requires identifying all of the stakeholders interested in diagnostic errors. Besides the physician, who obviously is at the center of the issue, many other entities potentially influence the rate of diagnostic error. Foremost amongst these are healthcare organizations, which bear a clear responsibility for ensuring accurate and timely diagnosis. It is doubtful, however, that physicians and their healthcare organizations alone can succeed in addressing this problem.
      At least in the short term then, we clinicians seek to enlist the help of another key stakeholder—the patient, who is typically regarded as a passive player or victim. Patients are in fact much more than that. Finally, there are clear roles that funding agencies, patient safety organizations, oversight groups, and the media can play to assist in the overall goal of error reduction. What follows is advice for each of these parties, based on our current—albeit incomplete and untested—understanding of diagnostic error (Table 1).
      Table 1Recommendations to reduce diagnostic errors in medicine: stakeholders and their roles
      Direct and MajorRole
      Physicians• Improve clinical reasoning skills and metacognition
      • Practice reflectively and insist on feedback to improve calibration
      • Use your team and consultants, but avoid groupthink
      • Encourage second opinions
      • Avoid system flaws that contribute to error
      • Involve the patient and insist on follow-up
      • Specialize
      • Take advantage of decison-support resources
      Healthcare organizations• Promote a culture of safety
      • Address common system flaws that enable mistakes
       —Lost tests
       —Unavailable experts
       —Communication barriers
       —Weak coordination of care
      • Provide cognitive aids and decision support resources
      • Encourage consultation and second opinions
      • Develop ways to allow effective and timely feedback
      Patients• Be good historians, accurate record keepers, and good storytellers
      • Ask what to expect and how to report deviations
      • Ensure receipt of results of all important tests
      Indirect and SupplementalRole
      Oversight organizations• Establish expectations for organizations to promote accurate and timely diagnosis
      • Encourage organizations to promote and enhance
       —Feedback
       —Availability of expertise
       —Fail-safe communication of test results
      Medical media• Ensure an adequate balance of articles and editorials directed at diagnostic error
      • Promote a culture of safety and open discussion of errors and programs that aim to reduce error
      Funding agencies• Ensure research portfolio is balanced to include studies on understanding and reducing diagnostic error
      Patient safety organizations• Focus attention on diagnostic error
      • Bring together stakeholders interested to reduce errors
      • Ensure balanced attention to the issue in conferences and media releases
      Lay media• Desensationalize medical errors
      • Promote an atmosphere that allows dialogue and understanding
      • Help educate patients on how to avoid diagnostic error

      Healthcare systems

      Leaders of healthcare systems recognize the critical role their organizations play in promoting quality care and patient safety. Unfortunately, in the eyes of organization leaders, “patient safety” typically refers to injuries from falls, nosocomial infections, the “never” events, and medication errors. Healthcare leaders need to expand their concept of patient safety to include responsibility for diagnostic errors, an area they traditionally have been happy to relegate to their physicians. Surprisingly, most diagnostic errors in medicine involve factors related to the healthcare system.
      • Graber M.L.
      • Franklin N.
      • Gordon R.R.
      Diagnostic error in internal medicine.
      Addressing these problems could substantially reduce the likelihood of similar errors in the future. Even the cognitive aspects of diagnostic error can to some extent be mitigated by interventions at the system level. Leaders of healthcare organizations should consider these steps to help reduce diagnostic error.

       System-related Suggestions

       Ensure That Diagnostic Tests Are Done on a Timely Basis and That Results Are Communicated to Providers and Patients

      Insist that tests and procedures are scheduled and performed on a timely basis.
      • Schiff G.D.
      Introduction: communicating critical test results.
      Monitor the turn around time of key tests, such as x-rays. Ensure that providers receive test results and that a surrogate system exists for providers who are unavailable. Unless this system functions flawlessly, establish a pathway for patients to receive critical test abnormalities directly, as a backup measure.

       Optimize Coordination of Care and Communication

      Develop electronic medical records so that patient data is available to all providers in all settings. Encourage interpersonal communication among staff via telephone, e-mail, and instant messaging. Develop formal and universal ways to communicate information verbally and electronically across all sites of care.

       Continuously Improve the Culture of Safety

      Include diagnostic errors as a routine part of quality assurance surveillance and review; identify any adverse events that appear repeatedly as possible examples of normalization of deviance. Monitor consultation timeliness. Ensure medical records are consistently available and reviewed. Strive to make diagnostic services available on weekend/night/holiday shifts. Minimize distractions and production pressures so that staff have enough time to think about what they are doing. Minimize errors related to sleep deprivation by attention to work hour limits, and allowing staff naps if needed.

       Suggestions Regarding Cognitive Aspects of Diagnosis

       Facilitate Perceptual Tasks

      Take advantage of suggestions from the human-factors literature on how to improve the detection of abnormal results. For example, graphic displays that show trends make it more likely that clinicians will detect abnormalities compared with single reports or tabulated lists; use of these tools could allow more timely appreciation of such matters as falling hematocrits or progressively rising prostate-specific antigen values. Computer-aided perception might help reduce diagnostic errors (e.g., as adjunct with mammograms to detect breast cancer). Controlled trials have shown that use of a computer algorithm can improve both the specificity and sensitivity of cancer detection more than an independent reading by a second radiologist.
      • Jiang Y.
      • Nishikawa R.M.
      • Schmidt R.A.
      • Metz C.E.
      • Doi K.
      Relative gains in diagnostic accuracy between computer-aided diagnosis and independent double reading.

       Provide Tools for Decision Support

      Provide physicians with access at the point of care to the Internet, electronic medical reference texts and journals, and electronic decision-support tools. These resources have substantial potential to improve clinical decision making,
      • Garg A.X.
      • Adhikari N.K.J.
      • McDonald H.
      • et al.
      Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review.
      and their impact will increase as they become more accessible, more sophisticated, and better integrated into the everyday process of care.

       Have Appropriate Clinical Expertise Available When It's Needed

      Don't allow front-line clinicians to read and interpret x-rays. Ensure that all trauma patients are seen by a surgeon. Facilitate referral to appropriate subspecialists. Ensure that trainees are appropriately supervised. Encourage second readings for key diagnostic studies (e.g., Pap smears, anatomic pathology material that is possibly malignant) and encourage second opinions in general.

       Enhance Feedback to Improve Physician Calibration

      Encourage discussion of diagnostic errors. Encourage and reward autopsies and “morbidity and mortality” conferences; provide access to electronic counterparts, such as “Morbidity and Mortality (M & M) Rounds on the Web” sponsored by the Agency for Healthcare Research and Quality (AHRQ).
      Case and commentaries
      AHRQ [Agency for Healthcare Research and Quality] Web M&M, January 2008.
      Establish pathways for physicians who saw the patient earlier to learn that the diagnosis has changed.

      Patients

      Patients obviously have the appropriate motivation to help reduce diagnostic errors. They are perfectly positioned to prevent, detect, and mollify many system-based as well as cognitive factors that detract from timely and accurate diagnosis. Properly educated, patients are ideal partners to help reduce the likelihood of error. For patients to act effectively in this capacity, however, requires that physicians orient them appropriately and reformulate, to some extent, certain aspects of the traditional relationship between themselves and their patients. Two new roles for patients to help reduce the chances for diagnostic error are proposed below.

       Be Watchdogs for Cognitive Errors

      Traditionally, physicians share their initial impressions with a new patient, but only to a limited extent. Sometimes the suspected diagnosis isn't explicitly mentioned, and the patient is simply told what tests to have done or what treatment will be used. Patients could serve an effective role in checking for cognitive errors if they were given more information, including explicit disclosure of their diagnosis, its probability, and instructions on what to expect if this is correct. They should be told what to watch for in the upcoming days, weeks, and months, and when and how to convey any discrepancies to the provider.
      If there is no clear diagnosis, this too should be conveyed. Patients prefer a diagnosis that is delivered with confidence and certainty, but an honest disclosure of uncertainty and the probabilistic nature of diagnosis is probably a better approach in the long run. In this framework, patients would be more comfortable asking questions such as “What else could this be?” Exploring other options is a powerful way to counteract our innate tendencies to narrowly restrict the context of a case or jump too quickly on the first diagnosis that seems to fit.

       Be Watchdogs for System-related Errors

      In a perfect world, all test results would be reliably communicated and reviewed, all care would be well coordinated, and all medical records would be available and accurate. Until then, the patient can play a valuable role in combating errors related to latent flaws in our healthcare systems and practices. Patients can and should function as back-ups in this regard. They should always be given their test results, progress notes, discharge summaries, and lists of their current medications. In the absence of reliable and comprehensive care coordination, there is no better person than the patient to make sure information flows appropriately between providers and sites of care.

      Other stakeholders

      Oversight organizations such as the Joint Commission recently have entered the quest to reduce diagnostic error by requiring healthcare organizations to have reliable means to communicate test results. Healthcare organizations by necessity pay attention to Joint Commission expectations; these expectations should be expanded to include the many other organizational factors that have an impact on diagnostic error, such as encouraging feedback pathways and ensuring the consistent availability of appropriate expertise.
      Both the lay media and professional journals could further the cause of accurate and timely diagnosis by drawing attention to this issue and ensuring that diagnostic error receives a balanced representation as a patient safety issue. The media also must acknowledge a responsibility to promote a culture of safety by desensationalizing medical error. If there is anything to be learned from how aviation has improved the safety of air travel, it is the lesson of continuous learning, not only from disasters but also from simple observation of near misses. The media could substantially aid this effort in medicine by emphasizing the role of learning while deemphasizing the emphasis on blame.
      Thus far, funding agencies have underemphasized diagnostic error in favor of the many other aspects of the patient safety problem. This type of error is not regarded as one of the low-hanging fruit.
      • Graber M.L.
      Diagnostic error in medicine: a case of neglect.
      Although diagnostic error is estimated to cause an appreciable fraction of the adverse events related to medical error,
      • Berner E.
      • Graber M.L.
      Overconfidence as a cause of diagnostic error in medicine.
      funded grants related to diagnosis are scarce. An obvious problem is that the solutions are less apparent for diagnostic errors than other types of mistakes (e.g., improper medication), so perhaps this imbalance simply reflects a lack of grant applications. If the funding were available, applications would follow.
      Patient safety organizations could play a substantial role in advancing diagnostic accuracy and timeliness simply by bringing attention to this issue. This could take the form of dedicated conferences, or perhaps simply advancing diagnostic error as a featured theme at patient safety conferences and gatherings. In addition to drawing attention to the problem, these forums play an invaluable role in bringing together people interested in solutions, thus allowing for networking and synergies that can more rapidly lead the field forward.

      Conclusion

      In summary, the faint blip of diagnostic error is finally growing stronger on the patient safety radar screen. An increasing number of publications are drawing attention to this issue. Research studies are starting to appear that use human factors approaches, observational techniques, or health services research protocols to better understand these errors and how to address them. In the proper order of things, our knowledge of diagnostic error will increase enough to suggest solutions, and patient safety leaders and leading healthcare organizations will begin to outline goals to reduce error, measures to achieve them, and monitors to check progress. A measure of progress will be the extent to which both physicians and patients come to understand the key roles they each can play to reduce diagnostic error rates. For the good of all those who are affected by diagnostic errors, these processes must start now.

      Author disclosures

      Mark L. Graber, MD, has no financial arrangement or affiliation with a corporate organization or a manufacturer or provider of products discussed in this article.

      Acknowledgements

      This work was supported in part from a grant from the National Patient Safety Foundation. We are grateful to Eta Berner, EdD, for review of the manuscript and to Grace Garey and Mary Lou Glazer for their assistance.

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