When it comes to information technology (IT), clinicians and hospitals might advise, "Be careful what you wish for." Embraced as the answer to many of healthcare's safety problems, technology provides useful tools that may improve but in no way guarantee safety. In fact, health IT can introduce as well as prevent or catch errors and must be designed, implemented, and monitored carefully, like any other tool used in patient care.1
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Research findings have been an important component of the growing interest in diagnostic error. Early studies and expert opinion raised awareness that diagnosis is a patient safety issue and began to identify the need to define diagnostic error, assess incidence rates, identify contributing factors, examine economic impact, and evaluate improvement strategies.1–7 Despite limited funding, this early research has been fruitful, providing evidence on these points, as well as direction to address the many gaps that remain.
Despite years of improvement efforts, reliable communication of test results continues to be a patient safety problem.1 In 2005, the Joint Commission on Accreditation of Healthcare Organizations (now The Joint Commission) included "reporting critical test results and lab values…to the appropriate licensed caregiver" on its list of National Patient Safety Goals for hospitals.2 Ten years later, "Get important test results to the right staff person on time" is still on the list3 and remains the only patient safety goal that directly addresses diagnostic error.
Between 60% and 80% of newborn babies develop jaundice during the first week of life. Most cases resolve with treatments that include phototherapy and transfusion. Left untreated, the yellow pigment found in bile, or bilirubin, that causes jaundice may in a small percentage of cases reach levels high enough to cause permanent brain damage and a disorder called kernicterus.1
Researchers identified two flaws in typical diagnostic support systems: physicians rarely use them, and when they do, it's often after already forming a biased diagnosis. A trial of 297 GPs found those given computer suggestions early (right after intake) were 1.31 times more likely to reach the correct diagnosis than those given no support or late-stage support, which performed similarly.
Nurses participate in the diagnostic process in different ways, depending on experience, training, certification, state regulations, and the culture of the organizations in which they practice. Recent changes in healthcare delivery present new opportunities, especially in primary care, for nurses to improve the diagnostic process. These changes also pose new opportunities for partnership with other clinicians, especially physicians.
Upadhyay, Sittig, and Singh find many "teachable moments" in their review of the case of "Ebola US Patient Zero." The story of that patient, Thomas Eric Duncan, is well known: Soon after arriving in Texas in September 2014 from his native Liberia, Duncan came down with symptoms consistent with Ebola infection and went to a hospital emergency department in Dallas. He was evaluated, given a diagnosis that "included sinusitis," and sent home. He returned to the same ED when his symptoms worsened. He was admitted to the hospital, diagnosed with Ebola, and died eight days later.
Humility, empathy, and compassion are personal qualities that improve relationships among clinicians, patients, and families and affect clinical outcomes.1,2 Confidence is another attribute that characterizes many expert clinicians and is perceived positively by patients.
Catastrophic medical malpractice payouts in the United States. Bixenstine PJ, Shore AD, Mehtsun WT, et al. J Healthc Qual. 2013;36(4):43–53.
Simulation is a technique used to immerse students in models of real-world situations where they may explore, learn, and practice with time, focus, and feedback not usually available. In healthcare, simulation allows students and clinicians to develop new knowledge, skills, and behaviors without putting patients at risk.
Stories of self-diagnosis, especially about serious or rare conditions that have been missed by physicians, are easy to find on the Internet and often heard at healthcare conferences. In the archetype, patients feel abandoned, left to their own devices, and at odds with physicians. The narratives usually feature patients who are motivated, persistent, and creative in solving diagnostic riddles while their physicians reject the patient's information and knowledge and are ineffective due to cognitive bias, burnout, rote adherence to pathways, and other professional and system problems.
"You can't manage what you can't measure," as the saying goes. In efforts to reduce diagnostic error, measurement is a challenge for many reasons: definitions of diagnostic error are evolving, the presentation of diagnostic errors is complex, and methodologies used to measure these errors in the past were limited at best, especially for outpatient settings.
Since the 1990s, patient safety experts have aspired to principles of "high reliability" that have resulted in excellent safety records in other hazardous industries, such as aviation and nuclear power. Those principles describe characteristics of organizational and workforce culture that must be adapted for application in specific workplaces and have not been easy to define and implement in healthcare. As research and improvement efforts focus on diagnostic error, some are asking how principles of high reliability can be applied to diagnosis.
Self-confidence affects how individuals approach making decisions and performing tasks. Whether they overestimate or underestimate their abilities will affect the quality of the judgments and choices they make. These common dynamics affect medical practice and may contribute to poor clinical judgments, faulty decisions, and diagnostic errors.
As the demand for clinical documentation grows, physicians find themselves torn between attending to patients and recordkeeping, often working on computer systems that are distracting for physicians and patients alike. One way for physicians to manage this dilemma is to partner with a medical scribe who creates a record of patient visits in real time. When used effectively, scribes can produce detailed clinical notes, improve physicians' access to information such as laboratory and test results, and remove the distraction of data entry from the patient-physician encounter.
We may assume that when doctors make errors in diagnosis, it is because of something they don't know. A new study, however, reveals it is more likely the opposite; they are led astray by something they do know—salient distracting features. This occurs when something familiar leaps to mind, having the effect of aiding and abetting the doctor to premature closure on the wrong diagnosis. Premature closure is an error in cognition, meaning to prematurely lock on to an (incorrect) diagnosis and fail to consider or pursue evidence to the contrary.
Communication problems are known to contribute to preventable adverse events of all kinds, including those caused by diagnostic error. The Joint Commission identified inadequate communication as the leading root cause of all reported sentinel events in 1995 through 2007. In 2011 and 2012, communication ranked a close third, behind human factors and leadership, and in January through June 2013, rose to second place, behind human factors.