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.

19 replies »

  1. I’m glad your discussing this, Bob.

    There is nothing in medicine more important than getting the correct diagnosis; to impress yourself on this point, just imagine how important it is in the field of mental health….years and thousands of dollars and lives waisted mistreating a borderline, or a manic depressive disorder.

    Anyway, here are some of my ideas on this (as a retired pathologist, practicing since the pleistocene epoch):

    1. Wisdom of crowds–try to get patients discussed in meetings and committees and in pickup conversations in the docs’ coffee room.
    2. Look at the size of the patient base–the total numbers of people cared for–and use this to help you find what is going on from a statistical basis. E.g. you have 1000 patients under your care. You should have 60-80 diabetics. You should have 80-90 hypertensives. You should have a few hemochromatosis patients and cystic fibrosis patients and asthmatics and COPDs, and depressed patients…on and on. How are you doing with each of these subsets? When was the last time someone cancelled appendicitis surgery because of an acute intermittent porphyria diagnosis?
    3. The hospital is only a tool. Insist that it provide the resource for CME that is convenient, certified, low cost or free, has a few sandwiches, etc., absent pharma conflicts, and frequent and run by the physicians and nurses. Get your groups to participate. Don’t tolerate the hospital cancelling your CME schedules. If speakers don’t show, schedule MOOCs or Grand Rounds from a university center.
    4. Try to get the docs to visit lab and radiology to talk to techs and their professionals. Tangential ideas from mid-level providers are very important.
    5. Try to get everyone to read nursing notes.
    6. You can’t have coordination of care–and superior diagnoses–if hospiitalists don’t talk to family practioners. Arrange for something formal to happen here.

  2. They are specifically tracking diagnostic errors, not medication errors, charting errors, etc.

  3. Results here:
    “Combining estimates from the three studies yielded a rate of outpatient diagnostic errors of 5.08%, or approximately 12 million US adults every year. Based upon previous work, we estimate that about half of these errors could potentially be harmful. ”
    Note that half, or 2.5% were considered potentially harmful, I assume life-threatening.

  4. This is how the study characterized misdiagnosis:

    “Methods Data sources included two previous studies that used electronic triggers, or algorithms, to detect unusual patterns of return visits after an initial primary care visit or lack of follow-up of abnormal clinical findings related to colorectal cancer, both suggestive of diagnostic errors. A third study examined consecutive cases of lung cancer. In all three studies, diagnostic errors were confirmed through chart review and defined as missed opportunities to make a timely or correct diagnosis based on available evidence. We extrapolated the frequency of diagnostic error obtained from our studies to the US adult population, using the primary care study to estimate rates of diagnostic error for acute conditions (and exacerbations of existing conditions) and the two cancer studies to conservatively estimate rates of missed diagnosis of colorectal and lung cancer (as proxies for other serious chronic conditions).”

  5. Not sure what you mean by “error” versus “mistake,” John. Perhaps what you’re getting at is preventable error in diagnosis? For example, some adverse drug reactions are not preventable; e.g., an unknown drug allergy. Similarly, there may be some errors in diagnosis — and “mistake” sounds way too judgmental — that are unavoidable.

    Certainly, some errors are malpractice, whether in diagnosis or otherwise; perhaps that’s what you meant by “mistake.” But I don’t think that’s the main focus here.

  6. again, how do we distinguish between an error and a mistake?

    misdiagnosis is an important issue that musy be studied, but there are many ways of approaching the question. Lets think it through ..

  7. The recommendations from Dr. Berenson’s group are unquestionably good ones, but would it not be important to try to gain insight in to why errors and misdiagnoses occur?
    My educated guess is too much multitasking. The essence of diagnosis includes time to get a good history and perform physical examination with the utmost attention. If there are too many distracting factors, it is very easy to miss something. I am also convinced there is an intuitive place in the minds of most medical practitioners honed over time of knowledge and experience. If one is unable to allow that space to open up, it will also be easy to miss something “not quite right”.
    All the technology and information can be at our disposal, but I also think it is critical to be able to have a quiet moment in our brains to process what we are hearing and seeing. With all the extraneous intrusions into physician practices and limited time slots for patient encounters, it is not surprising we have so many diagnostic errors, but that we don’t have more.

  8. Truth is stranger than parody!

    I get told this all the time: “never miss. Oh, whilst you are at it please don’t overcall.”

    Have they not heard of signal theory?

  9. We want you to diagnose everything accurately, but quit ordering so many dang expensive tests! Sounds like a plan…

  10. One way to avoid missing the triple threat (pulmonary embolism, dissection and acute coronary syndrome) is by getting a triple rule out CAT scan (yes they exist) in anyone with any conceivable symptom that has historically ever been associated with these entities.

    We will never miss one of the big three but there will be an awful lot of negative studies. Soon the negative studies will be called waste and inspire some policy analysts to study the association between waste and perverse incentives, drinking fair trade coffee and voting for the Republican party.

    Information is imperfect. We may resent this fact and resent those who acknowledge this reality, but that is not going to make it any more perfect.

  11. Some of us did read it before posting

    It’s fascinating, but has very little to do with the world of day-to-day medicine. We work in the worst possible environment for achieving accuracy in diagnosis, and we see that it is getting worse every day. 12 minute office visit, Medicare patient with 8 active problems, throw in the alphabet soup I described above: forget diagnostic precision, we’re talking about crisis management. It would be easier to cut diamonds while riding the Coney Island Cyclone at midnight. Patients hate it, doctors hate it, but we’re not the ones running the show. Excuse my cynicism.

  12. First, a suggestion to posters: yes, this is a blog post, but it’s about a very readable report from the Urban Institute. Before commenting, I recommend a quick scan to the link Bob posted. Even a cursory look will show you that it addresses the following as ways to improve diagnosis: Enhanced research
    Improved “conditions of participation” in Medicare; quality improvement and collaboration; follow-up and feedback; fundamental medical malpractice reform; Improved technology and electronic health record; payment reform; medical education reform.

    So: what does all that mean in English? The long list is simply a way of saying that we need to use all the various levers at our disposal to change a culture that has regarded diagnostic errors as “inevitable.” As I’ve written previously for the Health Affairs blog (see: http://healthaffairs.org/blog/2010/12/06/why-we-still-kill-patients-invisibility-inertia-and-income/), it is the failure to truly see errors as preventable that is the biggest barrier to change.

    We’ll never achieve perfection, but we can make significant progress. The report by Berenson and colleagues is important for not only what it says, but who is saying it (respected researchers) and who is funding this policy paper (the Robert Wood Johnson Foundation).

    There’s also a subtext here that clinicians would do well to heed. Would you rather work on diagnosis errors in a professional context, as suggested here, or within the context of, say, Congressional hearings prompted by NBC News? Bravo to Bob for getting us started down the right road.

  13. Well, the question – it seems to me – is going to be how do we define a misdiagnosis? Do we use a tight capture or a broad definition?

    When we’re talking about misdiagnosis, are we talking about the really bad outcomes – i.e. the cancers that kill people because we completely missed them – or are we talking about cases where we mess up.

    Technology is giving us the tools to track everything – but at a certain point (see the coding discussion and the exponentially increasing number of theoretically possible quality measures), but I’m not sure .

    What can we learn from the lessons of the quality movement?

    Michael? Anyone else?

  14. The question is, does all the above contribute to the inability to focus on diagnosis instead of all that other BS?

  15. I’m confused. Is making the correct diagnosis more or less important than: CPT bullets, MU requirements, ICD coding, Medicare PQRS, diabetic shoe requests, Viagra pre-auths . . .?

  16. So here’s my question – and I’ll keep it short and hopefully to the point- how do we frame this conversation and this initiiative in such a way that we avoid turning tracking diagnosis errors into a punitive thing?