Having the wrong diagnosis is literally killing some 40,000 to 80,000 Americans a year, and that's just in the hospital, according to a new coalition that is aiming to alert clinicians, patients, and health systems to their errors and to encourage them to find ways to be accurate and timely in determining what ails an individual.
"If you don't have an accurate diagnosis, everything that happens afterwards is potentially wasted money, it's potentially harmful — unnecessary side effects, unnecessary procedures — and meanwhile, the underlying problem is getting worse because it's not being treated," said Paul Epner, MBA, MEd, CEO and co-founder of the Society to Improve Diagnosis in Medicine (SIDM), which is spearheading the effort.
"Everything in healthcare starts with the right diagnosis," Epner told reporters and others gathered at the National Press Club in Washington, DC, on September 13 to hear about the new campaign.
SIDM has formed a coalition with 40 organizations — ranging from the major medical societies, patient safety organizations, academic medical centers, and health systems to quality improvement groups — to start working on eliminating the barriers to better and faster diagnosis, in a campaign they are calling ACT, which stands for "Accurate, Communicated, and Timely."
"The first step is the big one — everyone needs to understand that we have a problem," said Mark Graber, MD, president and co-founder of SIDM, in a statement that was delivered by Lisa Sanders, MD, associate professor of medicine at Yale School of Medicine, New Haven, Connecticut, and author of the New York Times Magazine column "Diagnosis."
Graber was not able to attend, but in his statement he said the diagnosis problem could be addressed. "The problem is how to get from where we are to better," he said.
Among the initial "simple" steps he's recommending:
Doctors learn about cognitive error;
Nurses be mainstreamed into contributing to the diagnostic process;
Healthcare organizations allow enough time for each visit and provide decision support and better communication; and
Patients begin to understand the diagnostic process and "help co-produce the diagnosis."
One area that's become increasingly fraught with error: clinical lab tests. Reynolds Salerno, PhD, director of the Laboratory Systems Division at the Centers for Disease Control and Prevention (CDC), said that some 260,000 labs conducted 13.8 billion tests in 2017. The number of tests performed is increasing 5% to 10% a year, but in most cases, the tests are highly reliable, said Salerno.
The errors are coming instead primarily from clinicians, he said. "The problems continue to occur in the test selection process, as well as the test interpretation process," Salerno said. The CDC is trying to encourage labs to work with clinicians to understand the thousands of tests available and help them with interpretation, he said.
To Err Is Human, but Taboo
Several people attending the briefing mentioned that while error was commonplace in everyday life, it was often a forbidden or ignored topic among clinicians and healthcare systems.
Sanders said that when she began writing her column in 2002, "I had never heard the phrase 'diagnostic error.'" Instead, "Like many physicians, I thought of diagnosis as a process and believed that all the incorrect diagnoses made on the way to the right diagnosis were simply steps in a complicated process," said Sanders.
But, she now knows that is incorrect and that the "twists and turns" she documents in her columns about the steps to getting a correct diagnosis are actually diagnostic errors.
"We will always make mistakes in healthcare," said David Mayer, MD, vice president of quality and safety at the Columbia, Maryland-based health system, MedStar Health, noting that he probably makes 20 to 30 mistakes a day himself, including sending emails without an attachment. "And yet we expect healthcare providers to be perfect."
The system needs to move away from blaming and learn more about what roles human factors play in what are often faulty systems and processes, said Mayer. He said healthcare professionals were doing the best they could with what they'd been given. "I've never met a healthcare provider, be it a physician, nurse, or pharmacist, who comes to work to harm somebody. They come to heal," said Mayer.
But the harm is occurring and is often irreparable, noted Epner, who said that during the 1.5 hours of the briefing, at least 10 Americans would die because of a missed or delayed diagnosis.
Michael Night from Orlando, Florida, shared the story of how, in 2015, his son John Michael was not given a swift diagnosis of a stroke, in part, it seemed, because he was 17, healthy, and athletic — even though he had hallmark symptoms. After several days, a dissection of a major artery was discovered on MRI. Now, the son is still unable to communicate verbally, is wheelchair-bound, and spends 6 days a week in occupational and physical therapy, Night said, breaking into tears.
Barriers and Solutions
In early 2018, the SDIM coalition members met to lay out the obstacles they've faced in getting to a timely and accurate diagnosis. Among those they identified are:
Incomplete communication during care transitions;
Lack of standardized measures for hospitals, health systems, or physicians to understand their performance in the diagnostic process, to guide improvement efforts, or to report diagnostic errors (providers said they rarely get feedback if a diagnosis was incorrect or changed);
Limited support to help with clinical reasoning;
Limited time, especially rushed appointments;
A complexity of process, with limited information available to patients about questions to ask, or what constitutes serious symptoms, and lack of clarity on who is responsible for closing the loop on test results and referrals and how to communicate follow-up; and
Lack of funding for research to quantify the impact of inaccurate or delayed diagnoses on healthcare costs and patient harm and on what improves the diagnostic process
Some coalition members have started to take action, said Epner.
The American College of Physicians (ACP), for instance, has developed a continuing education course of case studies to encourage thinking around diagnostic decision making, how problems may occur in that process, and how diagnostic errors may affect both patients and clinicians.
The ACP said it estimates that internists make errors in 10% to 15% of cases. Not only do they lead to substantial morbidity and mortality, but diagnostic errors are the leading type of paid medical malpractice claim and are nearly twice as likely to result in death as any other category of error, according to the ACP.
Source : https://www.medscape.com/viewarticle/9020141210