“The Biggest Mistake Doctors Make” is diagnostic

The Wall Street Journal ran a special report on healthcare this week and included two great articles that both referred to the Isabel diagnosis decision support tool:

• One article entitled "The Biggest Mistake Doctors Make"  covers diagnosis errors and
• Another looking at apps entitled "Healthcare Apps That Doctors Use"

Diagnostic error received scant attention only 2-3 years ago but now consumer press articles in highly respected papers such as the Wall Street Journal and peer reviewed studies in high impact journals are appearing frequently.

This lack of attention has always seemed odd when internal analysis of serious incidents invariably finds missed or late diagnosis to be the cause wherever it happens.

A recent study looking at appropriate prescribing of antibiotics using decision support even found the real problem was that the initial diagnosis made was incorrect over 30% of the time. This demonstrated the complete futility of trying to improve healthcare without improving diagnosis, the first and most important decision made about the patient

Bob Wachter is one of the leading patient safety figures in the USA and writes a very popular blog. He recently wrote one called “Diagnostic Errors: Central to Patient Safety, Yet Still In the Periphery of Safety’s Radar Screen”. The first comment made to the article was profound and is included in full below:

“You can either have excuses or get results–but you can’t have both.

Several years ago, our integrated system recognized the limitations of the National Quality Forum’s Serious Reportable Events and The Joint Commission’s Sentinel Events. Some of our leaders added a few additional events, one of which is: “Death or Serious Disability After a Missed Diagnosis”. This is a Board level report that triggers a full event response–immediate actions including a full Root Cause Analysis, identification of causative factors, action plans, and sharing across the system.

Next week, I will be presenting our monthly events to the Board. It’s a solemn and sombre experience. This month, half of our new events are diagnostic errors.

We certainly don’t have all the answers when it comes to diagnostic error, nor do we have all of the solutions.

We have changed the culture by identifying Diagnostic Error as a system failure until proven otherwise. In doing so, we’ve provided visibility to a closeted issue, begun the long journey of learning, and most important, started to heal our patients and staff for many events that seem frankly incomprehensible.

You can wait around for Superman or Godot or you can control your own destiny. I strongly advocate the creation of a structure within your own healthcare systems to learn, share, prevent harm, and heal.”

I firmly believe that the great tool to help improve diagnosis is the differential diagnosis. It's been taught for over 100 years yet is not carried out in routine practice in spite of research showing a differential diagnosis that includes the correct diagnosis is the most accurate predictor of diagnostic accuracy. Lack of time is often the reason given for not doing this but with modern diagnosis decision support tools available for clinicians and symptom checkers available for patients there should be a renewed focus on carrying out the valuable discipline of working up a comprehensive differential diagnosis.