Perspective: Diagnostic Errors – SIDM works to eliminate them

By Charles A. Pilcher MD FACEP
October, 2015

On September 27-29 I joined over 300 other healthcare professionals in Washington DC for an international conference on “Diagnostic Error.” This is an annual event sponsored by the Society to Improve Diagnosis in Medicine.  Meeting attendance has grown rapidly over the past few years and I was encouraged to find so many like minds working so hard to improve patient safety by reducing diagnostic errors.

Among the speakers was Dr. Victor Dzau, President of the National Academy of Medicine and Chair of the Institute of Medicine (IOM). You may recall that it was the IOM who published the original “To Err is Human” report that suggested that some 100,000 lives were lost each year due to medical error. Last month the IOM’s most recent report, “Improving Diagnosis in Healthcare”  was released. Media reports have focused on the report’s claim that “most people will experience at least one diagnostic error in their lifetime, sometimes with devastating consequences.” A free download of this report is available here.

We also heard from Richard Kronick, Ph.D., Director of the Agency for Healthcare Research and Quality (AHRQ) who acknowledged the importance of doctor-patient communication and family engagement in decreasing error rates. He also spoke of transparency in sharing our mistakes and said that increased transparency is the “low hanging fruit” in our quest for patient safety. However, when challenged during the Q & A session about sharing the outcomes of med mal settlements to help educate physicians, his response was disappointing. His voice noticeably lowered, he seemed embarrassed at having no answer and instead asked the questioner “What do you think we should do?”

The presentation that made the biggest impression on me was by Dr. Amanda Walker of the “Clinical Excellence Commission” of New South Wales, Australia, on their “Take 2 – Think – Do” campaign. All of us in medicine who study diagnostic error are aware of the importance of “critical thinking” and “self-awareness.” Dr. Walker and her team have boiled down this concept to a succinct “recipe” for success:

  • Take 2 minutes to deliberate the diagnosis. While deliberating;
    – Document the differential diagnoses
    – Detect any deviations from the presumed diagnosis
    – Debate the diagnosis at handoff
    – Decide on the final diagnosis
  • Think: Take a closer look and think again when
    – There are patient, system and/or cognitive factors present that may impact diagnostic decision making;
    – Do a re-check at certain patient journey checkpoints (e.g. Rapid Response Calls, Transfers to another unit)
    – Take 2 for you (what’s the “worst case scenario;” is this a high risk presentations)
  • Do: Take action:
    – Use a self- imposed diagnostic time-out; listen to your conscience in high risk situations)
    – Challenge a colleague to assess your assessment (The Aussies use a “Red Team/Blue Team Challenge promoting dialogue around decision making)
    – Seek a second opinion or consultation, refer or escalate

Stay tuned for more on this conference. SIDM is a great group of educators and researchers teaching the rest of us how to improve patient safety, reduce diagnostic errors and decrease the frequency of medical malpractice lawsuits. It is a 501.c.3 organization, and joining requires only a minimum contribution of $100.

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