Diagnostic errors, be it a failure to diagnose or a wrong diagnosis, have resulted in more paid malpractice payments than any other malpractice claim over the last 15 years, a study in BMJ Quality & Safety revealed earlier this month.
Co-author of the study Dr. David Newman-Toker said diagnostic errors resulted in “the most frequent, most severe, and most costly of medical mistakes” from 1986 to 2010.
“We published this paper in part because we wanted to express the magnitude of the problem,” said Newman-Toker. “There may not be a magic-bullet solution, but we’ve got to start monitoring and measuring and reporting these errors.”
According to the data:
- 28.6% of all paid malpractice claims from 1986 to 2010 were diagnostic errors.
- 27.2% were treatment errors.
- 24.2% were surgical errors.
- 6.5% were obstetrics errors.
- 5.3% were medication errors.
- 3% were anesthesia errors.
In addition, diagnostic errors were more likely to result in death than any other kinds of mistakes.
The most common diagnostic error was failure to diagnose (54.2%), followed by delay in diagnosis (19.9%), and wrong diagnosis (9.9%). 16% of cases were unclassified.
Diagnostic Errors Difficult to Prevent
The reason diagnostic errors are the leading cause of malpractice claims is because they are often very hard to prevent. If a doctor suspects a patient has one virus, but in fact they are suffering from something else, this can cause a delay in getting the correct treatment.
“If you give someone the wrong diagnosis, it may be days or weeks or months or years before they get the right diagnosis,” Newman-Toker said.
Newman-Toker also said diagnostic errors are problematic because they can’t be prevented by other safety measures. While wrong-site amputation accidents have severely decreased with new double-checking protocols, no such system can prevent diagnostic errors.
“Diagnosis isn’t simple,” Dr. Newman-Toker said. “You’re alone with a patient in a room, asking questions. There are 100 different possibilities. You face uncertainty and time pressures. You may lack scientific knowledge. You could be looking at an early (and less defined) stage of disease.”
Newman-Toker said that perfection may be unattainable, but with better testing procedures and expanded medical knowledge, we should be able to lower the rate of diagnostic errors.
Dr. Silverman comments
A line in my training rings in my head: “You can teach a monkey to operate, you just can’t teach them when.”
Diagnostic errors plague all doctors including Orthopedic Surgeons. One of my mentors once asked me, “What kind of doctor do I want to be? Do you want to be right 85% of the time, or more often?” At the time, it was a nonsensical question as I strove for A’s all the time. Who would ever be satisfied with being right 85% of the time? That would mean that 15% of the patients would get incorrect diagnoses and incorrect treatment.
Over the years, I have learned why this was even a question. An 85-percenter will apply the most common diagnose to the complaints and physical examination of the patient. They will be correct very often (more than 4 out of 5 times). They will be fast at coming to the diagnosis and they will appear to be very knowledgeable because of their speed. Patients who are well served will adore these doctors as they seem to work miracles and don’t make them wait in the office. Lots of their friends will be similarly happy. These doctors can actually see more patients and make more money in the same amount of time. They will make a lot of people very happy, but they will do harm to those who aren’t suffering from the most common disorder.
Well, I never did anything the easy way and I wasn’t about to start then or now.
I have never stopped striving to beat the 85%. In fact, anything less than perfection bothers me to my core. My patients know this. I can’t predict what complexity of patient will walk (or often enough hobble) in my door. I consider my practice one of tertiary care. I am a sub-specialist in Orthopaedic Surgery. I manage the most complex foot and ankle problems. I never turn down anyone no matter how complex the problem. I routinely see patients who have undergone surgery from other doctors, and I am often asked to provide my legal opinion regarding such cases.
Being this open means that some days I will have only easy operations, but other days a structure that resembles a foot or ankle will roll in attached to a patient in a wheelchair with a prayer hoping I can make them better.
Patients will sit in my waiting room sometimes for 1.5 hours wondering what the heck could be taking me so long. But, after the visit, they know why. I give every patient all the time they need. That includes all the time I need to make the diagnosis and formulate the best series of options, and all the time the patient needs to ask questions and understand how I made the diagnosis. You might think I would get faster as I get older and wiser, but I don’t. While I get smarter (in doctor terms that means faster at pattern recognition of rarer more complex patterns); the patients don’t get smarter. They all need the same amount of teaching time. And as I spend more time in the practice, more people refer me to complicated patients.
Will I be wrong sometimes? Of course, every doctor makes incorrect, incomplete and delayed diagnoses, but I know they are incredibly infrequent. This paper points out why just looking at the obvious mistakes, the never-events, is only scratching the surface. We need to constantly strive to do better, be smarter and be right more often.
Related source: Medscape