Monday, 12 June 2017

The diagnostic process and medical errors

The past 15 years, since the publication of "To Err Is Human" report, has seen a great deal of progress in projects that promote patient safety, especially in programs such as increasing hand washing, identifying patients, surgical checklists or changes in nursing care, but on the other hand the diagnostic process continues to be a matter almost exclusive to medical work although it’s known that this is a very sensitive area for the safety of patients. This new report from the National Academy of Medicine (formerly Institute of Medicine), "Improving Diagnosis in Healthcare," is a follow up document to the aforementioned one, specifically focused on diagnostic errors.

The report defines the diagnostic error as the failure to obtain a detailed, timely explanation of a health problem. Experts have also included in the definition the physician’s inability to know how to explain the diagnosis to the patient. According to the report, diagnostic errors would have an incidence on medical consultations of 5%, accounting for 10% of deaths, 6-7% of adverse reactions in hospitals, as well as the leading cause of litigation in the health area (the figures correspond to the US).

Seven recommendations to improve the diagnostic process

In Chapter 9 of the document, "The path to improve diagnosis and reduce diagnostic errors" (page 355) there’s a list of recommendations, from which I have extracted the following:

1. More communication between doctors and patients. It would be desirable to create a climate in which patients were informed and comfortable during the diagnostic process, despite the inconveniences and worries that the implicit expectations imply. Doctors should be empathic enough to know how to keep the patient well informed of each step taken as well as of steps not taken, with explanations for each case.

2. More effective teamwork. More collaboration is needed between clinicians and specialists in the field of diagnosis: pathologists, radiologists, analysts, etc. This same cooperative climate should also exist between family doctors and specialists.

3. More basic clinical training. Pressured by the popular admiration for diagnostic tests, and especially for the images, it would be advisable for the doctors to return to the origins of clinical reasoning (cultivating more of the Bayesian thinking) and to have more confidence in the basic clinical methodology: antecedents, health problems and exploration (it’s known that there are physical exams that are more predictive than imaging tests).

4. Knowing how to frame the use of IT. Many of the apps and gadgets are not clinically validated and act as a distracting factor in the relationship between doctors and patients, especially in complex diagnostic processes. This doesn’t mean that IT’s are bad, but the report admits that IT’s in this field are yet to find their comfort zone.

5. Learn from near-misses and mistakes. It’s necessary to foster an attitude that is prone to analyse near-misses and errors as a source of learning. This will have to overcome the dominant culture of fear of lawsuits and the unconstructive search for guilt.

6. Reorient directions by objectives by economically encouraging doctors to listen more to patients in clinical practice and to collaborate more with colleagues during diagnostic processes.

7. More research. More research needs to be done on the frequency of errors, their circumstances and how they can be avoided.

The video focuses on the idea that doctors should pay more attention to what the patients say, because they often have perceptions that can be very useful for clinical reasoning. In Carolyn's account, or in the story of Sue's son, one can see how the doctors’ arrogance prevented them from being sufficiently attentive to the signals that the patients uttered. In the third case, Jeff explains how, thanks to effective communication between specialists, he was timely operated on for an aortic aneurysm.

To summarize, in order to reduce diagnostic errors, the recipe has three fundamental ingredients: a) listening more and better to patients; b) cooperating more among colleagues, and c) encouraging basic clinical training. Apart from this, there are four other condiments (frame IT, learn from mistakes, encourage and investigate) that should also help in reducing diagnostic errors.

Jordi Varela

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