Breaking Down the IOM Committee Report On Diagnostic Error—Part One
David Meyers, MD, FACEP
On September 22, 2015, the Institute of Medicine (IOM) of the newly renamed National Academies of Science, Engineering and Medicine issued the report of its Committee on Diagnostic Error. As many of you know from my prior reports in this newsletter, the Committee was convened in early 2014 at the urging of the Society to Improve Diagnosis in Medicine (SIDM) and a number of other interested parties, among them government agencies such as the Agency for Healthcare Research and Quality, the Centers for Disease Control and Prevention; professional societies – the American College of Radiology.
American Society for Clinical Pathology, the College of American Pathologists; charitable foundations and private individuals.
The report gained immediate attention, particularly for the statement that “It is likely that most of us will experience at least one diagnostic error in our lifetime, sometimes with devastating consequences.” Although exact figures on the prevalence of such errors is not known, estimates from the literature suggest these rates of diagnostic error: 5% of adults who seek outpatient care; 10% in autopsy findings; 6-17% of reported hospital adverse events. Of course, it is well known that the majority of paid malpractice claims involve diagnostic errors, and a significant number of them involve the patient’s death.
The Report’s 3 key themes are:
- Diagnostic Errors are a significant and underappreciated health care quality challenge
- Patients are central to the solution
- Diagnosis is a collaborative effort
The Committee’s conceptual model consisted of 4 elements:
- Define Diagnostic Error
- Describe the Diagnostic Process
- Understand Work System Factors that Influence the Process
- Identify Outcomes form the Diagnostic Process
Defining “diagnostic error” posed challenges. There are a number of definitions extant, encompassing different elements and used for different purposes: day-to-day clinical care, research (in diagnosis decision-making, for example), in the medico-legal context and others. An in-depth discussion resulted in adoption of a new definition: “the failure to (a) establish an accurate and timely explanation of the patient’s health problem(s) or (b) communicate that explanation to the patient.” Of note is that the name of the patient’s condition is not part of this definition. Rather they chose to talk about the patient’s “health problem(s)”, and includes “communication” of the explanation to the patient in order to emphasize the centrality of the patient to the process. Over diagnosis, defined as “when a condition is diagnosed that is unlikely to affect the individual’s health and well-being”, was also addressed in the Report.
The diagnostic process is “team-based”, occurs over time, involves uncertainty and is influenced by the “work system”. It is iterative, with information gathering taking place over time with feedback. The goal of each step is to reduce diagnostic uncertainty, narrow down the diagnostic possibilities, and develop a more precise and complete understanding of a patient’s health problem. The process, components and its outcomes are represented in this schematic:
The areas the Committee specifically identified as needing improvement are:
- Education and Training
- Health IT
- Identification and Learning
- Work System and Culture
Areas where more evidence is needed include:
- Medical Liability
- Measurement for Accountability (e.g., Public Reporting)
Taking all this into consideration, the Committee identified 8 goals to improve diagnosis and reduce diagnostic error which will be discussed in the second portion of this article that will be published in the next QIPS newsletter.
Meanwhile, we can all get started on improving diagnosis by downloading and reading the Report of the Committee on Diagnostic Error, available on-line at http://iom.nationalacademies.org/Activities/Quality/DiagnosticErrorHealthCare.aspx. I invite comments and questions.