Surprising facts on diagnostic errors: Change practices to stop avoidable suits
It’s the number one reason for successful malpractice suits
Diagnostic errors are the leading cause of successful medical malpractice claims, according to a recently published analysis of 350,706 paid claims occurring from 1986 to 2010 from the National Practitioner Data Bank.1 Diagnostic errors represented 29% of the claims and accounted for 35% of total payments ($38.8 billion). Payouts were higher for severe disability, such as quadriplegia or severe neurological injuries, than for death.
Diagnostic errors in outpatient and ambulatory care clinics more commonly resulted in malpractice suits than inpatient errors, but inpatient errors were more deadly. “That’s in keeping with what you’d expect,” says David E. Newman-Toker, MD, PhD, the study’s senior author and associate professor in the Department of Neurology at Johns Hopkins Hospital in Baltimore, MD. “There are a lot more outpatients, so a lot more errors will happen. But the risk that they are life-threatening is lower than in the hospital setting.”
Diagnostic errors resulted in death more than other allegation groups (41% compared with 24%). The fact that serious morbidity was more common than mortality was somewhat surprising to the researchers. “We had good numbers before on deaths, but not good epidemiologic information on injuries short of death,” says Newman-Toker. “We really didn’t know a lot about morbidity associated with diagnostic error, in terms of its general prevalence in the population.”
William R. Forstner, JD, an attorney in the Raleigh, NC office of Smith Moore Leatherwood, says, “We have seen a number of initial diagnostic determinations which turned out not to be correct. These arise often in radiology reads of head CT or spinal imaging, but also within traditional medicine.” Here are items that Forstner says if documented, can make a misdiagnosis claim more defensible:
• Information that shows the clinical team was focused on the patient’s condition.
The record should reflect regular monitoring and attention, as well as timely treatment for the presumed diagnosis. “Documentation should show adequate attention was paid to the patient’s symptoms and potential medical needs,” says Forstner.
• The clinician’s conclusion that additional or different treatments should be considered if the current care does not address the patient’s condition.
For example, a physician might document, “If the patient’s condition does not improve on antibiotics after 48 hours, consider X.”
• Negative symptoms that help to rule out particular conditions.
For example, physicians might document “patient denies chest pain,” “no evidence of redness/swelling,” or “white blood cell count not elevated.”
“Including multiple diagnoses in a differential diagnosis can cut both ways,” adds Forstner. It shows that a physician is evaluating the patient’s condition to determine possible causes, and it helps avoid the argument that a physician is covering for a mistake after the fact by claiming to have believed the patient had a different illness or injury.
“However, not every possible diagnosis can be or is treated,” Forstner says. “It can help or hurt a defendant if the ultimate diagnosis was considered, but not treated, earlier in the patient’s course.”
Area is “scientifically immature”
Creating strategies to reduce diagnostic errors is “an area that is still scientifically immature,” says Newman-Toker. “There are a number of things that people have developed or attempted.”
None of these practices have been studied extensively in terms of their impact in reducing diagnostic error, he notes, though many have been studied for their immediate impact on simulated cases. Here are some practices for providers to consider, which might reduce liability risks of diagnostic errors: 2
• Monitor your own natural tendencies to overestimate or underestimate the likelihood of a particular diagnosis based on bias, rather than sound reasoning.
• Use diagnostic checklists to make sure you have considered all the possibilities for a patient’s symptoms, especially when there are red flags, such as the patient returning multiple times for the same complaint without a firm diagnosis.
• Take a “diagnostic timeout.” “This is like a surgical timeout. Make sure you are taking a deliberate pause, if this is a patient you didn’t give your full attention to, because you were distracted, or a high-risk case,” Newman-Toker says.
EMRs “not there yet”
Better devices, better diagnostic tests, computer-based decision support, and improved diagnostic education are on the horizon, says Newman-Toker, but “the EMR is not yet there, in terms of doing good diagnostic decision support.”
Some electronic medical records flag abnormal test results that never were followed up on, subsequent tests that never were ordered, referrals that never were made, and unexpected revisits to a hospital or provider. “Some organizations are working to use the EMR to identify problems not only after the fact, but also in real-time, when something has gone wrong with the diagnostic process,” says Newman-Toker. “This is mostly being done around communication of test results.”
Newman-Toker is unaware of any EMRs that are set up to help physicians make a diagnosis in a patient with a new symptom such as headache or dizziness.
“These sorts of decision support aren’t yet accurate enough, efficient enough, or sufficiently well-tested for their impact on patient care to be incorporated right now,” he says. “As for where the EMR could go in the future, the sky is the limit in terms of what it could help us with.” (See related story, below, on misdiagnosis in primary care settings.)
References
1. Saber Tehrani AS, Lee H, Mathews SC, et al. 25-Year summary of US malpractice claims for diagnostic errors 1986-2010: an analysis from the National Practitioner Data Bank. BMJ Qual Saf 2013; doi: 10.1136/bmjqs-2012-001550.
2. Ely JW, Graber ML, Croskerry P. Checklists to reduce diagnostic errors. Acad Med 2011; 86(3):307-313.
Sources
• William R. Forstner, JD, Smith Moore Leatherwood, Raleigh, NC. Phone: (919) 755-8714. Fax: (919) 755-8800. Email: [email protected].
• David E. Newman-Toker, MD, PhD, Associate Professor, Department of Neurology, Johns Hopkins Hospital, Baltimore, MD. Phone: (410) 502-6270. Fax: (410) 502-6265. Email: [email protected].
• Hardeep Singh, MD, MPH, Assistant Professor of Medicine, Baylor College of Medicine, Houston. Phone: (713) 794-8601. Email: [email protected].
Common diseases are being missed — Insufficient time is risk in primary care In the primary care setting, the most commonly missed diagnoses were pneumonia (6.7%), decompensated congestive heart failure (5.7%), acute renal failure (5.3%), and primary cancer (5.3%), according to an analysis of 190 primary care diagnostic errors that occurred in 2006 and 2007 at two large facilities.1 Cough was the most common chief presenting symptom associated with a missed diagnosis. “People tend to think that a lot of diagnoses being missed relate to rare, unusual, and hard-to-diagnose conditions. But our study found that many common diagnoses were being missed in primary care settings,” says Hardeep Singh, MD, MPH, the study’s lead author, chief of the health policy, quality and informatics program at the Houston VA Health Services Research Center of Excellence and assistant professor of medicine at Baylor College of Medicine in Houston. For example, an elderly male with lymphoma presented with headache, cough, green sputum, and fever. However, the provider did not order labs or X-ray to evaluate for pneumonia. A “major finding” Patients often presented with common symptoms, such as cough, shortness of breath, or abdominal pain. Most of the process breakdowns could be traced back to the history and physical exam. “That is a major finding,” Singh says. “It suggests we are probably not spending enough time with the patient. This is something in the patient/physician encounter that needs to be revitalized.” Differential diagnoses were not documented up to 80% of the time. “To us, this finding suggests that there are some critical thinking processes that weren’t being documented,” Singh says. “Traditionally, when faced with uncertainty in the clinical encounter, we tend to think through the possibilities.” The providers might have done this, but there was no evidence of it in the chart. Singh thinks that documenting a differential diagnosis in the medical record itself helps physicians to consider other possibilities for a patient’s symptoms. “We think it’s a good exercise that people should do more of, but just don’t have the time for,” he says. Primary care physicians are caring for more complex patients in a highly fragmented healthcare system, and many of them commented about the paper’s findings. “They said they are so overwhelmed with the time crunch that they are not able to decipher the signal within the noise,” Singh says. “One of the things that we need to be thinking about is how to best support the cognition of the primary care doctor.” If physicians aren’t certain of the patient’s diagnosis, they should express that uncertainty upfront and give specific instructions such as, “It is very important that you call back if you are not better in two to three days because this could be something else,” says Singh, instead of letting the patient decide what to do. “Engage with patients more, and let them know they are in charge,” he advises. “Patients can play a pretty strong role in improving their own diagnosis.” Reference 1. Singh H, Giardina TD, Meyer AND, et al. Types and origins of diagnostic errors in primary care settings. JAMA Intern Med 2013; 173(6):418-425. |
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