By Richard Kronick, Ph.D.
A few weeks ago, the National Academy of Medicine (formerly the Institute of Medicine or IOM) released a long-awaited report on a subject of great importance to the AHRQ—how all health care stakeholders can more quickly identify, resolve, and reduce the incidence of diagnostic errors and improve patient safety.
The report Improving Diagnosis in Health Care, reveals that most people will experience at least one diagnostic error in their lifetime, whether it’s an incorrect diagnosis of a heart condition or a cancer diagnosis that’s delayed. These problems occur in all settings of care and harm an unacceptable number of patients. While data are sparse, these errors contribute to approximately 10 percent of patient deaths and between 6 percent and 17 percent of hospital adverse events. Diagnostic errors are also the largest category of paid medical malpractice claims and are almost twice as likely to have resulted in a patient death compared with other claims, according to the report.
Diagnostic errors occur for many reasons, including inadequate collaboration and communication among clinicians, patients, and their families; a health care system that isn’t designed to support the diagnostic process; limited feedback to clinicians about diagnostic performance; and a culture that discourages transparency and disclosure of diagnostic errors, which in turn may impede attempts to learn from these events and improve diagnosis, according to the report.
Consistent with IOM’s earlier report To Err is Human, which helped galvanize today’s patient safety movement, the report challenges patients, health care professionals, and organizations on what they can do to address this complex challenge. It identifies eight goals that touch on virtually every aspect of the health delivery system, from how patients and health professionals can better communicate to how diagnostic errors can serve as the catalyst for delivering safer care, which is at the core of AHRQ’s mission.
For example, the report calls for more effective teamwork in the diagnostic process among health care professionals, patients, and their families. AHRQ, in conjunction with the Department of Defense, developed TeamSTEPPS® , a teamwork system for health care professionals that’s been proven to improve communication and teamwork skills. Developed originally for the hospital setting, TeamSTEPPS versions have been created for office-based and long-term care settings and for use with patients with limited English proficiency. Communication and coordination challenges inherent in diagnostic work are conducive to solutions offered by TeamSTEPPS, which, for example, could help facilitate the type of robust and consistent followup, feedback, and learning among members of extended diagnostic teams, as recommended in the report. AHRQ will be examining how TeamSTEPPS can be adapted to promote better communication and collaboration among health professionals involved in the diagnostic process.
AHRQ endorses the report’s call for health professionals and organizations to partner with patients and families as “diagnostic team members” and to take their needs and preferences into account. An AHRQ-funded research team produced Improving Your Office Testing Process: A Toolkit for Rapid-Cycle Patient Safety and Quality Improvement to help ensure that diagnostic lab tests are accurately managed and shared with patients and clinicians in a timely manner. In addition, the Agency has long recognized the positive role of patient and family engagement in safer and better care. Our Patient and Family Engagement Guide helps health providers encourage patients and family members to be involved in the safety and quality of their care. And AHRQ’s Questions Are the Answer patient involvement campaign offers a wide range of resources to help patients get the best care possible. AHRQ will be examining whether these tools can be further developed or adapted to address diagnostic errors.
While acknowledging that many health care organizations have made progress in establishing a culture of safety, the new report calls for all health care systems to support the diagnostic process. This is where AHRQ is well positioned to help: we’ve invested in a suite of patient safety culture surveys that are being used in many health care settings around the country to identify trouble spots, and we’ve produced a variety of tools to help health care providers work together more seamlessly once problems are identified. We have also placed a special emphasis on funding patient safety work in ambulatory settings, where much diagnostic work occurs. But it’s still early days for this work, and more is clearly needed.
As with other threats to patient safety, valid approaches to measuring the extent of the problem will be a fundamental contributor to addressing challenges with the diagnostic process. The IOM report notes that we are unable at this point to reliably measure the number of diagnostic errors or their causes and that this measurement gap is an impediment to making progress. AHRQ strongly agrees with this assessment, and is exploring the development of standardized methods for reporting and as well as other measurement strategies to capture information about diagnostic error in a reliable and efficient way. The report recognizes the significant role that Patient Safety Organizations can play in this effort, citing the need for safe and confidential environments to support learning from diagnostic error. AHRQ will continue to engage with PSOs and consider how their capabilities and the services they offer to providers in conjunction with the protections provided through the Patient Safety and Quality Improvement Act can most effectively contribute to improving diagnosis and other safety and quality challenges.
Fifteen years ago, To Err is Human galvanized the issue of patient safety and prompted many improvements in care delivery. Today, a similar opportunity exists to reduce patient harm from diagnostic errors. AHRQ is prepared to embrace the ambitious and important goals this report outlines.
About the Author: Richard Kronick, Ph.D., is Director of the Agency for Healthcare Research and Quality. This article was originally published on AHRQ Views Blog and is republished here with permission.