Reducing misdiagnosis: Time for the next chapter in improving patient safety

In an opinion piece published in the New England Journal of Medicine, Dr. Hardeep Singh of Baylor and the DeBakey VA and Dr. Mark L Graber of RTI International in Raleigh-Durham, North Carolina said the recent Institute of Medicine report on "Improving Diagnosis in Health Care" requires individual and collaborative action from all health care stakeholders nationwide.

Diagnostic errors involve several types of missed opportunities to make a correct and timely diagnosis; a diagnosis may be missed completely, the wrong one may be provided, or diagnosis may be delayed, all of which can lead to harm from delayed or inappropriate treatments and tests.

"Diagnosis is the foundation of medicine; without the right diagnosis, patients don't receive the right treatment," Singh said. "Understanding the importance of diagnostic errors has been difficult because they are difficult to detect and understand and less amenable to systems-based interventions."

During the past decade, Singh and his colleagues at DeBakey VA Medical Center for Innovation in Quality, Effectiveness, and Safety (IQuESt) and Baylor's section of health services research have quantified the issue in a series of studies, many of which were cited in the Institute of Medicine report.

"Using rigorous methods, we found that diagnostic errors affect 12 million United States adults per year, or 1 in 20 adults per year, and it's the common diseases that get missed," Singh said. Among those "misses" are infections, heart disease and cancer, said Singh and Graber.

He said that recommendations for systems and process changes made by the Institute of Medicine need to be established in doctors' offices, clinics and hospitals and could lead to improved and safer care for patients.

In addition to making patients a partner of the diagnostic team, the recommendations from the Institute of Medicine include:

• Reforming the teaching of diagnosis.
• Ensuring health information technology supports the diagnostic process.
• Strengthening teamwork.
• Measuring and learning from errors.
• Promoting a culture of diagnostic safety.
• Increasing research funding.
• Reforming the malpractice and reimbursement systems.
• Promoting a culture of diagnostic safety.

Singh said that one of the first steps should be for researchers and other safety professionals to develop resources to help institutions and clinicians figure out how to identify and measure diagnostic errors accurately.

"Diagnosis involves uncertainty. It is not always black and white and often evolves over time," he said. "We need more action research in this area so errors can be identified and we can learn from them."

The authors also recommended that both patients and practicing clinicians actively engage in generating solutions to reduce misdiagnosis.

"Doctors now have high rates of burnout due to administrative burdens, user-unfriendly electronic records, productivity pressures and reimbursement systems that don't support listening to patients and putting their stories together," Singh said. "We need to change situations that increase our risk of missing important patient symptoms."

The Institute of Medicine recommendations are only as useful as the action behind them, he said, noting that in addition to health policy and clinical practice changes, medical education reforms and interprofessional training programs could also enable doctors and their teams to make better diagnosis.