Diagnostic error is everyone’s responsibility – What can be done?

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Dr Peter Lachman
Dr Peter Lachman

While one may argue that diagnosis is mainly the responsibility of clinicians, it has been suggested that leaders and managers have a responsibility as well, writes Dr. Peter Lachman

In healthcare one of the roles of managers is to ensure that the conditions are right for clinicians to deliver high quality care within the available resources. As managers, we trust and rely on clinicians to deliver person-centred care which is safe and has diagnostic accuracy. Over the past few years this premise has been challenged with the growing literature on the problem of diagnostic delay and error.

A hidden part of clinical care is the challenge to minimise diagnostic error and to ensure that we have a proactive process to provide safe care. This requires the mechanisms to deal with potential delays or missed diagnoses. Most of the research has been in the USA and a recent paper has attempted to assess the burden of missed diagnosis. The paper’s writers estimated that diagnostic error is probably the single largest source of death across all care settings linked to medical error, with nearly 800 000 Americans dying or left permanently disabled by diagnostic error each year.(1) Now, due to the heterogeneity of the data it may be an overestimation, but even if it is, diagnostic error is still a problem. This problem is likely to present in Ireland as well, but we do not have the data.

The issue of diagnostic error was highlighted by Singh and Graber in the New England Journal of Medicine in 2015.(2) Since then the momentum has grown and more research is emerging, as this is a new frontier in patient safety.  So what are we talking about? The Institute of Medicine defines diagnostic error as the failure to establish an accurate and timely explanation of a patient’s health problem or to communicate that explanation to the patient. Singh has suggested that it is basically about missed, wrong or delayed diagnosis.(3) He suggests that we can proactively take measures to decrease the risk. While we can assume that we have competent clinicians, we need to provide them with structures to provide care, including time. Teamwork is essential, as one needs to be able to see problems from different angles. Also, by having a person-centred approach, listening to patients and their families and hearing them is fundamental.

Another dimension of the problem is that diagnostic errors and delays impact the most vulnerable populations most. A systematic review, including 20 studies on the treatment received for people presenting with cardiovascular problems to the emergency room, has demonstrated that diagnostic error can be related to the social determinates of health.(4) Patients from ethnic minorities, or who were socially deprived were less likely to have a correct diagnosis of their cardiovascular symptoms and therefore had a higher rate of diagnostic error. This finding did not hold for those presenting with symptoms of stroke, possibly as the clinical signs are more visible. The authors hypothesized that there are multiple reasons for diagnostic errors and delay in diagnosis. Other studies have demonstrated delays in diagnosis of jaundice and appendicitis in people from ethnic minorities . In the accompanying editorial it is proposed that we need to actively address the implicit biases that may exist and add this form of diagnostic error as part of any equity and education programme.(5)

While one may argue that diagnosis is mainly the responsibility of clinicians, it has been suggested that leaders and managers have a responsibility as well. We can take actions to facilitate a learning environment in which diagnostic errors are discussed openly, so that we can decrease the impact of missed diagnostic harm.(6)

Firstly, there needs to be recognition of the problem at Board and executive level, with accountability at every level of the organisation.

To facilitate reporting of diagnostic problems, a just culture is paramount within the envelope of psychological safety. This will ensure that people will speak about the problem.

Learning is essential and it requires feedback loops to allow for sharing across the organisation.

To maximise learning, the approach must be multi-professional, with all disciplines involved in the assessment of the problem.

Data must be collected. This is probably the black hole, as organisations do not routinely collect data on diagnostic errors.

Being transparent with data requires a culture of psychological safety which is often missing in our system. Measures based on Donabedian’s model of structure processes and outcomes can assist managers to develop a framework of measures to address the challenge.(7)

A patient led organisation, the Society to Improve Diagnosis in Medicine aims to improve diagnosis and provides some ideas.(8) It is clear that Improving diagnosis and clinical outcomes needs to be coproduced in partnership with patients, managers and clinicians. Working together with clinicians can make a real difference.

Reference

  1. Newman-Toker, D. E., Nassery, N., Schaffer, A. C., et al. (2023). Burden of serious harms from diagnostic error in the USA. BMJ quality & safety, bmjqs-2021-014130.Advance online publication. https://doi.org/10.1136/bmjqs-2021-014130.
  2. Singh H, Graber ML. Improving diagnosis in health care—the next imperative for patient safety. N Engl J Med. 2015;373:2493-2495. https://www.nejm.org/doi/10.1056/NEJMp1512241
  3. Singh, H. Diagnostic Errors: A New Chapter in Patient Safety Science, Policy, and Practice. (2016) PSNET. https://bit.ly/3smyzHR
  4. Herasevich, S., Soleimani, J., Huang, C., Pinevich, Y., Dong, Y., Pickering, B. W.,Murad, M. H., & Barwise, A. K. (2023). Diagnostic error among vulnerable populations presenting to the emergency department with cardiovascular and cerebrovascular or neurological symptoms: a systematic review. BMJ quality & safety, 32(11), 676–688. https://doi.org/10.1136/bmjqs-2022-015038
  5. Connor, D. M., & Dhaliwal, G. (2023). Moving upstream to address diagnostic disparities. BMJ quality & safety, 32(11), 620–622. https://doi.org/10.1136/bmjqs-2023-016130
  6. Singh, H., Mushtaq, U., Marinez, A., et al. (2022). Developing the Safer Dx Checklist of Ten Safety Recommendations for Health Care Organizations to Address Diagnostic Errors. Joint Commission journal on quality and patient safety, 48(11), 581–590. https://doi.org/10.1016/j.jcjq.2022.08.003
  7. Singh, H., Graber, M. L., & Hofer, T. P. (2019). Measures to Improve Diagnostic Safety in Clinical Practice. Journal of patient safety, 15(4), 311–316. https://doi.org/10.1097/PTS.0000000000000338
  8. Society to Improve Diagnosis in Medicine https://www.improvediagnosis.org