IHI Forum

I am attending the annual IHI forum, in Orlando far away from the arctic conditions at home. Amazing stuff,  spending the day at a course devoted to paediatric patient safety, with talks from the worlds experts in this area. Steve Muething, Cincinnati Children's talks about developing a high reliability organization in healthcare. Matt Scanlon, Milwaukee, talks about human factors and measurements in paediatric safety. Anne Matlow, Sick kids Toronto talks about the major problem of diagnostic error in children, pointing out that diagnostic mistakes account for 13-20% of adverse events, but are more likely to be preventable and are more likely to cause serious harm or death. Paul Sharek, Stanford discussed medication safety, raising the provocative point that although a great deal of money has been devoted to improving medication safety,  medication errors account for 20% of all errors and a much smaller proportion of serous harm.

Diagnostic Error; The Elephant in the Closet?

Diagnostic error as a cause of avoidable harm has received relatively little attention in the quality safety literature until recently. Diagnostic error is a diagnosis that is missed, delayed, or incorrect. Various estimates suggest that errors of diagnosis account for 40-80,000 deaths annually in the US. Autopsy studies have shown that in 5% of cases, a diagnosis is found which if known prior to death and treated appropriately could have averted death. Physician errors are more likely to occur from diagnostic mistakes than medication error; are likely to result in serious harm and more likely to result in bigger lawsuit payouts.  The causes of diagnostic error are complex, and as yet poorly understood. One concerning finding however is that a lack of knowledge or expertise is rarely the rimary factor; indeed, some researchers suggest that experienced doctors who have "a gut feeling" may be led astray by their experience. For further reading, I would suggest this paper by Pronovost. A talk at the recent Risky Business conference which discussed the psychological basis of error is well worth viewing. (Free to view, but registration required)
There are few data in paediatrics; a recent study reported that 50% of paediatricians had made one to two diagnostic errors in the previous month. 45% reported diagnostic errors that harmed patients at least once in the previous year.
So we have identified a big problem, conceivably more serious than medication harm; what is the solution? In truth, no-one knows. Suggestions include computer aided diagnostic tools, realistic simulation in training, more training!, reform of tort law. We need to start with the basics, and begin to understand the causes of diagnostic error, and only then can we begin to introduce solutions. Medicine is messy, diagnosis in contrast to treatment remains an art; we have to make it more of a science.