Improving Diagnostic Accuracy in Medicine
is diagnostic error?
- Diagnosis that is wrong, missed or delayed
do we know about diagnostic error?
- It’s frequent and harmful
- It’s under-recognized, under-studied and not
integrated into quality assurance measures or activities (Newman-Toker and
often does it happen?
- Approximately 5-15% of the time (Berner and
Graber 2008 and other sources)
do we get information about diagnostic error?
- Autopsy data
self -reports of experiencing diagnostic error
- Patient self-reports of experiencing diagnostic
- Databases of reported error
- Peer reviewed journal studies
- Medical malpractice claims data (Berner and
about malpractice claims data, isn’t it skewed?
- If other data sources tend to under-represent
diagnostic error and claims data tends to over-represent it (Graber and Berner
2008), then claims may serve as a balancing and confirming adjunct source
- Claims analysis reviews the patient viewpoint in
addition to the medical record, a viewpoint absent from most other data sources
- There’s abundant claims data available on
diagnostic error (NPDB, PIAA Data Sharing Report)
- There are many peer reviewed claims studies in
the literature (Griffen 2008, Studdert and Mello 2006, and others)
- Claims are strongly associated with adverse
events (Rand Corp. study 2010) such that if one is reduced or increased, so
goes the other.
often does diagnostic error lead to adverse events and death? How often is
death due to diagnostic error?
- Many errors are unknown (low rate of autopsy,
patient going elsewhere for care) therefore exact relationship not known
- Harvard Study showed diagnostic error accounting
for 17% of adverse events (Leape, Brennan 1991)
- In malpractice claims involving a death,
diagnostic error is far and away the top allegation at 26% (Physician Insurer,
diagnostic error more associated with hospital care than in the physician’s
Diagnostic error was the #1 cause of claims in ambulatory care and #2 in
hospitals (after improper performance of a procedure), but the totals were
fairly close (Bishop et al JAMA 2011,
based on NPDB data)
is the cause of diagnostic error?
- It’s multi-factorial and can present as a
perfect storm of multiple factors lining up:
6 factors on average were found per case of diagnostic error in an
internal medicine study (Graber 2005).
- Lack of physician knowledge is least often the
problem. It is more often due to
cognitive error, systems errors including communication errors, and most common
of all, the combination of cognitive and systems errors (Graber 2005).
is the difference between cognitive and systems errors?
- Cognitive errors take place in the physician’s
head— they concern the thinking process. An example is latching on prematurely
to a diagnosis and abandoning the search for evidence to the contrary.
- Systems errors occur between the inter-related
pieces in healthcare systems. Examples
include physicians or other practitioners dropping the ball in the
referral-consultation process or in the hand-off process. Another is lost or
unreported test results.
- In combination, it is often the systems error
that is the catalyst for adverse events and claims because 1) by definition a
systems error tends to replicate and amplify, and 2) the patient perceives it
as the error that didn’t have to happen, and 3) if the systems factor is peeled
away, the perfect storm may not transpire
diagnostic error more closely associated with some specialties than others?
- Yes, but it is a significant factor for claims
in all specialties.
- It is the #1 cause of medical misadventure
claims for all the primary care specialties (internal medicine, family and
general practice, pediatrics), radiology and emergency medicine, and most of
the medical sub-specialties.
- It is the #2 cause of medical misadventure
claims for the surgical specialties (OB-gyn, general surgery, orthopedics and
most of the surgical sub-specialties), but it is most often a close, not a
distant second place.
the rare diagnosis that is the subject of diagnostic error?
- No, it is the common diagnosis and the common
killers: heart attack, cancer and stroke.
- Overall, the top diagnosis in claims related to
diagnostic error is breast cancer (PIAA Data Sharing Report 1985-2009).
- Acute myocardial infarction is the top subject
of diagnostic error in claims for the specialties of adult primary care,
emergency medicine and cardiology (PIAA Data Sharing Report 1985-2009).
- Stroke is associated with diagnostic error 9% of
the time (Newman-Toker et al 2008).
- For family and general practice, the top
diagnoses involved in diagnostic error in descending order were myocardial
infarction, breast cancer, appendicitis, colorectal cancer and lung cancer.
- In a study of physician self-reported diagnostic
errors, the diagnoses most often involved were pulmonary embolism, drug
reaction or overdose, lung cancer, colorectal cancer, acute coronary syndrome,
breast cancer and stroke (Schiff et al 2009).
- Certain diagnoses like pulmonary embolism and
aortic dissection may not be found until autopsy, but the rate of autopsies
performed in the US has declined steeply, so these and others are
under-detected at an unknown rate.
can be done to reduce diagnostic error and harm?
- Raise awareness of diagnostic error and its
importance among physicians, the public, healthcare organizations and funding
- Increase funding and attention to research into
causes and remedies for diagnostic error
- Develop the databases and guidelines to improve
clinical decision-making tools
- Integrate teaching about cognitive error and
diagnostic error into medical school curricula, resident training, and continuing education
- Include goals related to improving diagnostic
accuracy in quality improvement/quality assurance activities and measures
- Invest in and make available the following
things to the physician at the point of
care: clinical decision making support systems, electronic medical
records, integration of physician office-hospital-lab-imaging facility records,
and other aids to improve diagnostic accuracy
- Develop the means to measure diagnostic error
and provide report cards to practitioners
- Develop a corps of physician-champions dedicated
to improving accuracy in medical diagnosis, make international connections to
spread this initiative internationally
DIAGNOSTIC ERROR FACT SHEET
Bishop TF, Ryan AK, Casalino LP. Paid malpractice claims for adverse events in inpatient and outpatient settings. JAMA. 2011:305;2427-2431.
Data Sharing Project 1985-2009 and Special Reports. Physician Insurance Association of America (PIAA), Rockville, MD. For more information
Graber ML. Diagnostic errors in medicine: a case of neglect. Jt Comm J Qual Patient Saf. 2005;31:106-113.
Graber ML, Franklin N, Gordon R. Diagnostic error in internal medicine. Arch Intern Med. 2005;165:1493-1499. Free full text
Greenberg, MD, Haviland AM, Ashwood SJ, Main R. Is Better Patient Safety Associated with Less Malpractice Activity? Evidence from California. Santa Monica, CA: Rand Corporation, 2010. Free full text
Griffen FD, Stephens LS, Alexander JB, et al. Violations of behavioral practices revealed in closed claims reviews. Ann Surg.
Leape L, Brennan TA, Laird N, et al. The nature of adverse events in hospitalized patients: results of the Harvard Medical Practice Study II. N Engl J Med.1991;324:377-384. Free full text
Newman-Toker DE, Pronovost PJ. Diagnostic errors—the next frontier for patient safety. JAMA. 2009; 301:1060-1062.
Newman-Toker DE, Robinson KA, Edlow JA. Frontline diagnosis of cerebrovascular events in the era of modern neuroimaging: a systematic review. Ann Neurol. 2008:64(suppl 12):S17-18.
PIAA Data Sharing Project, Top alleged medical errors in
claims where the patient expired (DSP data 1985-2009). Physician Insurer Fourth Quarter 2010: 55.
Schiff GD, Hasan O,
Kim S, Abrams R et al. Diagnostic error in medicine, analysis of 583
physician-reported errors. Arch Intern Med. 2009;169:1881-1887. Free full text