Wednesday, May 25, 2011

Diagnostic error---the sleeping dog of patient safety?

Yes, at least according to patient safety expert Robert L. Trowbridge, MD, interviewed in a recent issue of Today's Hospitalist. Diagnostic errors, at least so called cognitive diagnostic errors, reflect on the physician's clinical skill. As Trowbridge pointed out:

If I prescribe the wrong medication or the wrong dose, I can justify that by saying that we all make mistakes. But when it's a critique of your thinking as a diagnostician, that cuts to the core of who you are as a physician.

According to Trowbridge that is why diagnostic errors have received little attention in the patient safety movement despite the fact that they are believed to account for a large portion of adverse events. Patient safety leaders, as I've repeatedly observed before, have turned safety concerns into a culture of blame. This policy-level finger of blame, at least up to now, however, has pointed largely at system failures and unavoidable outcomes, areas for discussion well within the comfort zones of most docs. Not necessarily so when you move the conversation to misdiagnosis.

The problem of misdiagnosis is largely unexplored territory in the patient safety field. Transparency is essential if progress is to be made. To that end Trowbridge has helped set up an anonymous reporting system at his facility. It seems like a great idea to me although I would eliminate references to error partly for the reasons just stated, but also because of the difficulty on multiple levels of adjudicating misdiagnoses as to the presence or absence of error.

Solutions? Trobridge mentioned decision support, the effective use of basic clinical skills and an idea I particularly like, the “diagnostic time out.” It's exactly what DB was talking about here.

1 comment:

Trisha Torrey said...

I suffered what may be among the most written-about misdiagnoses in current literature.

My misdiagnosis actually started in the lab, and then a second lab, and then the domino effect took it to an oncologist who saw a lab report for a zebra when, it turned out, I wasn't even a horse. Not only wasn't the oncologist willing to explore my questions about having possibly been misdiagnosed (based on the fact that I was supposed to be dead in a few months and was still playing golf twice a week), but he very vehemently and arrogantly told me I was foolish for seeking a second opinion.

The problem is that few doctors ever expect themselves to be wrong, and few patients ever consider that their doctors are wrong. Second opinions are not usually sought to find an alternative diagnosis; they are sought to learn about additional treatment options.

In many cases, a diagnosis can be wrong, but ultimately it doesn't matter. (If the diagnosis is for swine flu, does it matter if it's really seasonal?)

But for some, a misdiagnosis is deadly. When treatment does not appear to work, or when your patient continues to complain of problems you thought you had fixed, you owe it to yourself and your patient to explore differential diagnoses to figure out if it's possible something else is causing your patient to suffer.

It should not be about blaming. It should be about confirmation. At the extremes, the patient doesn't really have cancer (me) and a doctor doesn't get sued. Both are great outcomes.