Johns Hopkins patient safety experts say it's high
time for diagnostic errors to get the same
attention from medical institutions and caregivers as
drug-prescribing errors, wrong-site surgeries
and hospital-acquired infections.
Diagnostic misadventures represent a potentially much
larger source of preventable health
problems and deaths than many of the more popular targets
of safety reform, they say in a
commentary in the March 11 issue of the Journal of the
American Medical Association.
In the article,
David Newman-Toker and
Peter Pronovost
report that misdiagnosis accounts for
an estimated 40,000 to 80,000 hospital deaths per year and
that tort claims for diagnostic errors —
defined as diagnoses that are missed, wrong or delayed
— are nearly twice as common as claims for
medication errors.
Typically, they note, diagnostic errors were thought
to originate with individual doctors lacking
the training or skill they should have, but blaming
physicians hasn't produced many solutions. As with
successful approaches to reducing treatment errors, they
point out that reducing diagnostic errors
will likely require a focus on larger "system" failures
that affect medical practice overall.
"Moving away from a model that chastises individual
physicians to one that focuses on improving
the medical system as a whole could offer big payoffs for
improving diagnostic accuracy as well as the
cost-effectiveness of care," said Newman-Toker, assistant
professor of neurology with joint
appointments in
Otolaryngology,
Health Sciences Informatics,
Epidemiology,
and Health Policy
and Management at the Johns Hopkins University schools
of Medicine and Public Health. "Right now," he
said, "there is often a mismatch between who gets advanced
diagnostic testing and who needs it,
leading to worse outcomes and higher costs. Realigning
resources with needs could improve outcomes
at lower cost."
Much as bloodstream infections in intensive care units
have decreased through systematic
solutions adopted by hospitals, such as requiring
physicians to follow a procedural checklist that
emphasizes sterile techniques when inserting medical
catheters, Newman-Toker and Pronovost suggest
that systemwide solutions could be the key for decreasing
diagnostic errors.
For example, Newman-Toker noted, triage protocols in
emergency departments often
categorize patients with typically benign symptoms, such as
isolated headache, as being at "low risk"
of having a bigger problem even though such symptoms are
sometimes indicative of dangerous
conditions, such as a bleeding brain aneurysm. A systems
fix that could decrease diagnostic errors
might be to change the overall rules for the triage
protocol so that it considers specific symptom
details that help distinguish between "low risk" and "high
risk" types of headache.
The Johns Hopkins team suggests that diagnostic errors
might be reduced by systematically
adopting tools such as checklists that help physicians
remember critical diagnoses or by making
available computer programs known as "diagnostic
decision-support systems" that assist physicians in
calculating the level of risk of a given patient's having
certain diseases. Health systems could further
decrease diagnostic errors, they say, with time-tested
low-tech tools such as independent second
looks at X-rays and CT scans or rapidly directing patients
with unusual symptoms to diagnostic
experts.
Because diagnostic errors can be tricky to track to
their roots, Pronovost, an expert on
breaking down complex medical problems, says that more
research is needed to understand and find
patterns in the origins of such errors. Pronovost, a
professor of anesthesiology, critical care medicine
and surgery, is medical director of Johns Hopkins' Center for
Innovation in Quality Patient Care.
"The first step in addressing the diagnostic error
problem is to shine a light on [errors] so they
are clearly visible," Pronovost said. "Then, with wise
investments, clinicians, researchers and patients
can discover how to prevent them."
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