Wrong-site surgeries grab headlines, but the diagnostic errors that quietly occur in clinicians' minds are "the most frequent, most severe, and most costly of medical mistakes" among paid malpractice claims, according to a new study published online Monday in BMJ Quality & Safety.
Remarkably, the healthcare establishment largely tolerates diagnostic errors in the spirit of "You can't win them all" instead of attacking them with the same quality-improvement rigor that it applies to wrong-site surgeries, said study coauthor David Newman-Toker, MD, PhD, in an interview with Medscape Medical News.
"We published this paper in part because we wanted to express the magnitude of the problem," said Dr. Newman-Toker, an associate professor in the neurology department at Johns Hopkins University School of Medicine in Baltimore, Maryland. "There may not be a magic-bullet solution, but we've got to start monitoring and measuring and reporting these errors."
Dr. Newman-Toker and his colleagues found that these failures of the intellect accounted for 28.6% of 350,706 paid malpractice claims from 1986 to 2010, outstripping other causes of injury related to treatment (27.2%), surgery (24.2%), obstetrics (6.5%), medication, (5.3%), anesthesia (3%) and the like. Diagnostic errors were more likely to result in death (40.9%) than other kinds of mistakes (23.9%). Permanent disability was just as likely a consequence as death, suggesting that the "public health impact of diagnostic errors could be substantially greater than previously estimated based on autopsy data that consider only lethal errors."
Not surprisingly, diagnostic errors had the dubious distinction of generating the highest proportion (35.2%) of total payments. Over the 25-year span under study, payments for diagnosis-related malpractice claims (adjusted for inflation) came to $38.8 billion, with an average payout of almost $387,000.
A diagnostic error is not synonymous with a misdiagnosis. The most frequent diagnostic error was failure to diagnose (54.2%), followed by delay in diagnosis (19.9%), and wrong diagnosis (9.9%). The remaining 16% were unclassified.
The malpractice claims analyzed in the study had been reported to the National Practitioner Data Bank (NPDB), a federal repository of payments made on behalf of clinicians for court judgements or settlements. The NPDB is maintained by the US Department of Health & Human Services.
Diagnostic Errors Harder to Prevent
One reason why diagnostic errors are neglected in an era of quality improvement is that they are not as immediately apparent as a foot amputated by mistake, Dr. Newman-Toker told Medscape Medical News.
"If you give someone the wrong diagnosis, it may be days or weeks or months or years before they get the right diagnosis," he said.
In addition, preventing diagnostic errors is a daunting task that defies obvious solutions like double-checking with the patient about which foot to amputate before marking it.
"Diagnosis isn't simple," Dr. Newman-Toker said. "You're alone with a patient in a room, asking questions. There are 100 different possibilities. You face uncertainty and time pressures. You may lack scientific knowledge. You could be looking at an early (and less defined) stage of disease.
"It's a miracle we get any diagnosis right."
Although it's impossible to make the right call 100% of the time, Dr. Newman-Toker said, unattainable perfection is no excuse for inaction. "We can't say we're doing the best we can because we're not doing the best we can," he said.
Diagnostic errors top the list of reasons for paid malpractice claims despite the excessive testing associated with "defensive medicine," which seeks to avoid a missed diagnosis and a possible lawsuit. "We don't need more testing, but smarter testing," Dr. Newman-Toker asserted. Case in point: Emergency department physicians often subject patients complaining of acute dizziness to CT scans to rule out stroke, even though dizziness is a symptom of an ischemic stroke, which frequently doesn't show up on such scans. A better test would be a bedside eye movement assessment.
Dr. Newman-Toker also recommends that clinicians focus their quality-improvement energies on diagnostic errors that lead to the greatest patient harm. The clinical problems posing the highest stakes are vascular events, infections, and cancer, he said.
The authors reported no conflicts of interest.
BMJ Quality & Safety. Published online April 22, 2013. Abstract
Medscape Medical News © 2013 WebMD, LLC
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Cite this: Diagnostic Errors Dominate Malpractice Payouts - Medscape - Apr 23, 2013.