Researchers call for next chapter in improving patient safety by reducing misdiagnosis

In an opinion piece published in the New England Journal of Medicine, Mark Graber, M.D., a Senior Fellow at RTI International, and Hardeep Singh, M.D., of Baylor and the DeBakey VA said the recent Institute of Medicine report on "Improving Diagnosis in Health Care" requires individual and collaborative action from all health care stakeholders nationwide.

As president and on behalf of the Society to Improve Diagnosis in Medicine, Graber petitioned the Institute of Medicine to conduct this report and was a member of the report committee.

"The committee concluded that diagnostic errors are common," Graber said. "Each of us is likely to experience one or more diagnostic errors in our lifetime, some of which could have very serious consequences. Many of these errors could be prevented. Both unusual and very common diseases are being missed, including heart disease, cancer and infections."

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."

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, according to the researchers.

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 and making the patient a member of the diagnostic team
• Measuring and learning from errors and promoting a culture of diagnostic safety
• Reforming the malpractice and reimbursement systems
• Encouraging research to evaluate the many different interventions that have been proposed that could reduce the likelihood of error and harm.

According to Graber and Singh, 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," Singh said. "We need more active 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 create environments that promote reliable diagnosis."

"Improving diagnosis will require that each of the stakeholders in the diagnostic process takes the Institute of Medicine recommendations to heart, and develops concrete plans to begin addressing this serious and largely overlooked problem," Graber said.