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Landmark report on diagnostic errors unveiled by Institute of Medicine

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U.S. Army

Most Americans will get at least one faulty diagnosis in their lifetime, sometimes with devastating consequences and “urgent change is warranted to address this challenge,” a panel of medical experts said Tuesday.

In a landmark report by the Institute of Medicine, the medical arm of the National Academies of Sciences, Engineering and Medicine, the experts said that despite dramatic improvements in patient safety over the last 15 years, diagnostic errors have been the critical blind spot of health-care providers.

Exact figures on diagnostic errors are hard to come by, as reporting is not required. Some medical experts have estimated that more than 12 million adults are misdiagnosed every year.

“Despite the pervasiveness of diagnostic error and the risk for patient harm, they have been largely unappreciated within the quality-safety movement in healthcare — and this cannot and must not continue,” said Dr. Victor Dzau, president of the Institute of Medicine, an independent organization of the country’s leading medical and health policy researchers.

“Diagnostic errors are a significant contributor to patient harm and have received too little attention until now,” he said at a public briefing in Washington, D.C., about the report, “Improving Diagnosis in Health Care.”

To address the challenge, the IOM convened the committee comprised of medical and health policy researchers to improve diagnosis in medicine. The Committee on Diagnostic Error in Health Care members include experts from Stanford, Harvard, Drexel, Tufts, the Memorial-Sloan Kettering Cancer Center, Kaiser Permanente and more than a dozen other universities and national medical organizations.

“We defined diagnostic error from a patient's perspective, and brought together the research so far that clearly shows the opportunity and grave need to improve the current situation,” said Kathryn M. McDonald executive director of Stanford’s Center for Health Policy/Center for Primary Care and Outcomes Research, and a member of the IOM committee.

“The report is packed with reasons and directions for action from all, in ways that support what patients deserve from the health-care system: freedom from worry about inattention to diagnostic errors,” McDonald said. “That's been the status quo for too long.”

The committee issued a set of goals to reduce diagnostic errors and improve medical outcomes. They recommend that the health-care community:

  1. Facilitate more effective teamwork in the diagnostic process among health-care professionals, patients and their families.
  2. Enhance health-care professional education and training in the diagnostic process.
  3. Ensure that health information technologies support patients and health-care professionals in the diagnostic process.
  4. Develop and deploy approaches to identify, learn from and reduce diagnostic errors and near misses in clinical practice.
  5. Establish a work system and culture that supports the diagnostic process and improvements in diagnostic performances.
  6. Develop a reporting environment and medical liability system that facilitates improved diagnosis through learning from diagnostic errors and near misses.
  7. Design a payment and care delivery environment that supports the diagnostic process.
  8. And provide dedicated funding for research on the diagnostic process and diagnostic errors.

The experts emphasized that medical education must include more of an emphasis on the diagnostic process. And new technologies, such as electronic health records, should be built on better collaboration among the IT vendors, users and the Office of the National Coordinator for Health Information Technology.

The new study was an extension of two benchmark reports by the institute released 15 years ago, which revealed the startling statistic that 100,000 Americans die in hospitals every year due to medical errors.

“These landmark reports from IOM reverberated throughout the healthcare community and were the impetus for system-wide improvement in patient safety and quality,” Dzau said.

The Department of Health and Human Services reported in December that there was a decline from 2010 to 2013 in hospital-acquired infections, which translated to 1.3 million patients and $12 billion in health spending avoided.

“You can see we have come a long way,” Dzau said. But, he added: “The critical element that has been absent from patient safety and quality is diagnostic error.”

In a video released at the public briefing, two patients talk about their own misdiagnosis and that of a loved one, and how those errors forever changed their lives. They were told they were overreacting and not to question their doctor. One said she was embarrassed at having wasted the valuable time of the hospital doctors and nurses.

“The video has two patients for whom things went poorly and one who had a first-class diagnostic experience because of excellent teamwork,” McDonald said. “And this is one of the key messages of the report. We need less of the old model of diagnosis from one expert to more of a teamwork approach to the diagnostic process.”

Dr. John Ball, chair of the committee and executive vice president emeritus of the American College of Physicians, said clinicians must work toward a culture where patients are central to the solution.

“Patients and families are first; diagnostics are second and those who support it, third,” said Ball. “This is an issue that matters to patients, and we’re shining a light on it.”

Ball said getting the right diagnosis is critical because it impacts every other health care decision that follows, as well as the quality of life for the patient.

The committee members were asked during the briefing why they were not recommending that misdiagnosis reporting be mandatory, something that likely will lead to controversy.

“The committee believes that given the lack of agreement on what constitutes a diagnostic error, given the complexity of hard data and the lack of valid measurement approaches, the time was not right to call for mandatory reporting,” Ball said. “Instead it was appropriate at this time to leverage the intrinsic motivation of health-care professionals to improve the diagnostic performance and to treat diagnostic error in the same way we treat other quality improvement efforts by health-care organizations.”