Diagnosing the Problem
“The delivery of health care has proceeded for decades with a blind spot: Diagnostic errors—inaccurate or delayed diagnoses—persist throughout all settings of care and continue to harm an unacceptable number of patients. For example:
- A conservative estimate found that 5 percent of U.S. adults who seek outpatient care each year experience a diagnostic error.
- Postmortem examination research spanning decades has shown that diagnostic errors contribute to approximately 10 percent of patient deaths.
- Medical record reviews suggest that diagnostic errors account for 6 to 17 percent of hospital adverse events.
- Diagnostic errors are the leading type of paid medical malpractice claims, are almost twice as likely to have resulted in the patient’s death compared to other claims, and represent the highest proportion of total payments.”1
“The [Committee on Diagnostic Error in Health Care] definition of diagnostic error is the failure to (a) establish an accurate and timely explanation of the patient’s health problem(s) or (b) communicate that explanation to the patient….
Timeliness means that the diagnosis was not meaningfully delayed; however, timeliness is context-dependent. While some diagnoses may take days, weeks, or even months to establish, timely may mean quite quickly (minutes to hours) for other urgent diagnoses. A diagnosis is not accurate if it differs from the true condition a patient has (or does not have) or if it is imprecise and incomplete.”1
Source: Institute of Medicine
The 2015 Institute of Medicine (IOM) publication “Improving Diagnosis in Healthcare” takes an important step in the right direction with respect to identifying and avoiding medical error.1 I suspect many have adopted this document in toto based on its credible source and its premise of improving diagnostic accuracy in medicine. I do agree that the IOM has produced another powerful and important document overall, but I feel it did so, to a certain degree, at the expense of emergency medicine.
What I think is being missed in this whole discussion is that as more pressure is placed on diagnosing accurately and in a “timely” manner, the more likely we are to become experts at creating diagnostic error. Although diagnostic error expert Patrick Croskerry, MD, PhD, professor of emergency medicine at Dalhousie University in Halifax, Nova Scotia, and his work were both included in this paper, aren’t the heuristics, mental shortcuts, that Dr. Croskerry and others caution us to avoid only amplified by this additional pressure?
The IOM has clearly identified the emergency department as a high-risk environment. I certainly can’t disagree. However, from my perspective, an overemphasis has been placed on the ED, suggesting an overgenerous share of responsibility belongs to emergency physicians. As a matter of fact, the emergency department is mentioned no fewer than 48 times in its 369-page document. “For example, analyses of claims data could be used in ‘look back’ studies to identify the frequency with which acute coronary syndrome is misdiagnosed … explore how frequently these beneficiaries were seen by health care professionals in the week prior to ultimate diagnosis (either in outpatient, emergency department, or hospital settings), the incorrect diagnoses that were made, and the factors associated with the diagnostic error.”1 I don’t dispute that the ED should be involved in such programs, but I do question why others are omitted. Isn’t the ED an outpatient department, and aren’t most EDs part of a hospital? Then why is the ED singled out while other outpatient and hospital departments are not even mentioned?