The Ticklish Problem of Diagnostic Errors
The quality improvement (QI) community is becoming more active in working toward reducing diagnostic errors, but misdiagnoses remains an uncertain field, and some say they might well be nearly impervious to significant improvement.
Every physician knows that diagnostic errors are a problem—for the patient, who may needlessly suffer a bad outcome, and for a physician, who is concerned about his or her patient and may also end up with a malpractice lawsuit. But physicians also understand that getting the right diagnosis may take a while, and even with their best efforts, a diagnosis may not be right.
In September 2015, a report by the Institute of Medicine (IOM) declared that doctors and the healthcare system have a "moral, professional and public health imperative" to reduce diagnostic errors. To do so, the diagnostic process must be "re-envisioned," the IOM said.
This was the IOM's first report aimed at tackling diagnostic errors. Its 1999 report, To Err Is Human—credited with launching the QI movement—mentioned diagnostic errors only twice, according to Robert M. Wachter, MD, an authority on patient safety and health information technology at the University of California, San Francisco (UCSF).
When To Err Is Human was released, diagnostic errors were still widely seen as a problem that would be extremely difficult to address. Diagnoses were thought to be too nuanced, too difficult to measure, and inappropriate for QI. In 2010, Dr Wachter wrote a commentary titled, "Why Diagnostic Errors Don't Get Any Respect—and What Can Be Done About Them."
Even now, with the IOM on board, key metrics used to evaluate healthcare quality still don't include diagnostic error, says Mark Graber, MD, founder of the Society to Improve Diagnosis in Medicine and a member of the committee that wrote the new IOM report. "Not a single healthcare organization is measuring the incidence of diagnostic error in its own practices," he says.
Misdiagnosis is too big a problem to be ignored, Dr Wachter says. After all, diagnosis is the first step in the medical process. If you get it wrong, then everything that follows—prescriptions, surgeries and other therapies—will be wrong, too.
However, all of the factors that are involved in leading to misdiagnosis still exist. The IOM report doesn't call for elimination of diagnostic error. Its title—Improving Diagnosis in Health Care—focuses on a more modest goal.
Mark Graber, MD, says that although misdiagnoses can be markedly reduced, they never will be eliminated. He points to an article he cowrote, stating that there will always be "no-fault errors," which occur "when the disease is silent, presents atypically or mimics something more common."
Moreover, identifying diagnoses in real time is often complicated. It can sometimes take weeks or months of follow-up tests for doctors to identify the right diagnosis. And then, if a misdiagnosis is made, it may take years for it to become noticeable. Autopsies show that some patients die of diseases they were never diagnosed with.
The QI movement has already taken on medication errors, wrong-site surgery, and healthcare-associated infections, but Dr Wachter says improving diagnosis involves considerably greater challenges.
"In the absence of ways to measure diagnostic accuracy, we limited ourselves to process measures because they were easy to measure," he says. "But process measures show only part of the picture. You can score very well on process measures, but if your underlying diagnosis is wrong, there is still harm to the patient."
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Cite this: Leigh Page. Is Misdiagnosis Inevitable? - Medscape - Mar 28, 2016.