Make No Mistake! A Strategic Plan for Diagnostic Error

Kenneth W. Lin, MD, MPH


February 10, 2016

Editorial Collaboration

Medscape &

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Hi, everyone. I'm Dr Kenny Lin. I am a family physician at Georgetown University School of Medicine and I blog at Common Sense Family Doctor.

In 1999, the Institute of Medicine (now called the National Academy of Medicine [NAM]) published the report "To Err Is Human,"[1] which famously estimated that 44,000 to 98,000 Americans died from medical errors each year, the higher number being the equivalent of a jumbo jet crashing and killing everyone on board every day of the year. Since then, we have made a great deal of progress in improving patient safety, but most of these strides have occurred in hospital settings, through better infection-control practices in intensive care units or implementing surgical checklists in operating rooms.

In contrast, we know much less about how to prevent medical errors in outpatient settings where most people receive healthcare. Some inpatient interventions are easily transferable to the clinic. For example, by supporting medication reconciliation and flagging potential drug-drug interactions, electronic prescribing can prevent adverse drug events.

Other outpatient safety problems, such as diagnostic errors, will require different approaches. Last year's NAM report on "Improving Diagnosis in Health Care"[2] suggested that at least 1 in 20 adults are affected by diagnostic errors each year and that nearly everyone is misdiagnosed during their lifetime. This is not only because doctors miss unusual diagnoses—the so-called "zebras"—but fail to diagnose such common problems as heart disease or cancer. Many of these errors result from communication failures between patients and physicians, between primary care providers and specialists, or between different types of healthcare professionals. According to the NAM, medical culture must change to become more reflective and team-oriented to promote routine monitoring, open discussion, and feedback about diagnostic performance.

A draft report[3] on patient safety in ambulatory care settings, recently issued by the Agency for Healthcare Research and Quality (AHRQ) echoed the NAM's conclusions. Based on a literature review and interviews with developers of patient safety practices, policy makers, health organization safety supervisors, and a patient advocate, the AHRQ report identified six cross-cutting strategies to improve outpatient safety: communication, teams, patient and family engagement, organizational approaches, health information technology, and safety culture. What these strategies have in common is that they recognize that doctors won't improve safety on their own, simply by trying harder not to make mistakes.

Obviously, some diagnostic errors are more consequential than others. If the "hamstring strain" that I misdiagnosed in a patient a few weeks ago turns out to be lumbar radiculopathy, little harm is done. On the other hand, if the runner whom I misdiagnose with exercise-induced asthma really has a saddle pulmonary embolism, it could be disastrous. Still, interventions should target all diagnostic errors, regardless of their potential to injure patients.

As I have written about in the past, inpatient safety practices (such as checklists) might support better diagnosis in primary care. Still, family doctors can't, and shouldn't, count on the Peter Pronovosts and Atul Gawandes of the world to come up with practical solutions. So, it is good that leaders of the Society to Improve Diagnosis in Medicine plan to spearhead a national coalition of professional societies and other interested parties to translate the NAM report's recommendations into action.[4] To be successful, that coalition must include organizations representing primary care physicians, teachers, and researchers who understand the unique patient safety risks inherent in 15-minute office visits.

This has been Dr Kenny Lin for Medscape Family Medicine. Thank you for listening.


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