Placing Diagnosis Errors on the Policy Agenda

Robert Berenson“Not everything that counts can be counted, and not everything that can be counted counts.”

This aphorism has been deliciously, but, alas, incorrectly attributed to Albert Einstein (the saying actually has mixed origins, but credit properly might be given to sociologist William Bruce Cameron, writing in 1963).

But, whatever its provenance, the saying is particularly appropriate in describing the woeful lack of attention paid to the long-standing problem of diagnosis errors in the provision of health care services.

Last week academic researchers from Baylor and the University of Texas published important research estimating that one in 20 adults in the U.S., or roughly 12 million people every year, receive an error of diagnosis—a wrong, missed or delayed diagnosis—in ambulatory care.

This likely represents a conservative estimate of the incidence of such errors in ambulatory care and does not attempt to include inpatient hospital care or care provided in nursing homes and post-acute care facilities, such as rehab hospitals.

The news media correctly decided that this peer-reviewed finding deserved prominent attention—it was a lead story on “NBC Nightly News” and other national news programs.

It seems that attaching a large number to the prevalence of such errors provided the needed news hook to give the problem the attention it has long deserved. Surveys reveal that the public is worried as much about a misdiagnosis or missed diagnosis as any other quality and safety issue in health care.

Autopsy studies performed over time find that unacceptably high rates of diagnosis errors persist; similarly, diagnosis errors continue to represent a leading cause of medical malpractice suits.

But even without newsworthy body counts, the problem of diagnosis errors has been known to clinicians for decades, if largely ignored by stakeholders and policy-makers as a major quality and safety problem.

In 1912, physician Richard C. Cabot, writing in the Journal of the American Medical Association, suggested that, “A goodly number of ‘classic’ time-honored mistakes in diagnosis are familiar to all experienced physicians because we make them again and again.

Some of these we can avoid; others are almost inevitable [emphasis added], but all should be borne in mind and marked on medical maps by a danger-signal of some kind: ‘In this vicinity look out for hidden rocks,’ or ‘Dangerous turn here, run slow.’”

In our new paper on diagnosis errors  funded by the Robert Wood Johnson Foundation, we explore what is known about their prevalence and impact, the formidable challenges of routinely measuring them, and the reasons they persist despite the many advances in clinical research and care and in health information technology.

We also point to the role of physician specialty societies, medical educators, quality improvement organizations, and other stakeholders in more directly addressing this problem, and present a set of potentially fruitful public policy approaches to reducing these errors.

Such approaches include more active provider and patient reporting and feedback systems; earmarked research funding for studying the nature and extent of diagnosis errors; payment and delivery system reform; patient safety collaboratives; fundamental medical malpractice reform; and enhanced electronic health records and artificial intelligence software to support improved clinical decision-making.

In response to Dr. Cabot, a century later we argue that diagnosis errors should no longer be viewed as inevitable and, therefore, an acceptable—if regrettable—by-product of even high-quality health care.

Rather, these errors represent quality and safety failures that can be reduced substantially—even if we can’t measure precisely the impact of the many initiatives that can be mounted to address the problem.

Robert Berenson, MD, is an institute fellow at the Urban Institute.