Last week the Minnesota Department of Health published its Adverse Health Events report, detailing the occurrence and consequence of medical errors in the state during the previous year ("Annual report on Minnesota hospital errors finds problems with lost tissue samples" Feb 17). There are 29 categories tracked by the MDH, the so called "never events." These include wrong-site surgery, device or drug contamination, unsafe administration of blood or blood products, and medication errors involving the wrong drug, the wrong dose, the wrong patient, the wrong time, the wrong rate, etc.
The risk factor that isn't on this list of 29 — the risk that seems impervious to the best system design and checklist adherence — is inaccurate or delayed diagnosis.
In 2015, the National Academy of Medicine (NAM) published "Improving Diagnosis in Health Care." This latest in a series of reports that began in 1999 with "To Err is Human" continues to measure the frequency and significance of medical errors and set goals for the field of medicine. The 2015 report offers a stark prediction that, based on current practice, most everyone in the U.S. will experience at least one diagnostic error in their lifetime, sometimes, "with devastating consequences."
The NAM report offers eight strategies for improving diagnosis and reducing error. They include education and training, establishing and enforcing an effective feedback loop so lessons can be learned from errors and near misses, and a payment and care delivery system that supports the time and attention required for careful diagnosis.
But the two recommended strategies that stand out to me as a layman and a victim (my 15-year-old daughter Julia died 11 years ago as a result of diagnostic error) are teamwork and culture.
For generations we have expected answers, correct answers, from our doctors. We have trusted their judgment, conditioned perhaps by memories of a family doctor who took the time to recall our medical history and to talk to us, and who provided sound advice based on their experience and recollection of our idosyncracies.
But today, increasing specialization, the proliferation of tests and technology, and a growing dependence on electronic medical records increase the need for greater teamwork among the providers and a more deliberate effort to engage patients and families in the diagnostic journey.
Diagnosis is a process, best served by an honest and transparent curiosity shared between provider and patient. Doctors need to listen, question, and consider the options. Patients need to share accurately, answer honestly, and be willing to question the conclusion.
By engaging a patient in the diagnostic process, factors not previously revealed may lead to unexpected diagnostic alternatives.
Medical schools are developing better ways of teaching diagnosis and the cognitive traps that lead professionals to err. But an even greater shift is required, I think, in the culture of medical practice. Whether in outpatient visits or hospital admissions, providers need to embrace a culture of collaboration that accepts uncertainty as a given and humility as a virtue.
Doctors are going to make mistakes. The important thing is that they learn from them and, even more, that there is an institutional culture that supports rather than shames, and extends the learning to others.
I don't underestimate how difficult this can be. It takes courageous and consistent institutional leadership, and a commitment to due process as well as transparency. But as long as diagnostic and other errors continue to injure and kill patients, the urgency cannot be denied.
I've had an opportunity to tell my daughter Julia's story to medical students and the broader medical community locally and nationally. The topic of medical error is being addressed frequently and openly, and that is reason for hope.
Medical schools and programs of continuing medical education must maintain a drumbeat of awareness. They must promote collaborative diagnosis and foster a culture that is willing to acknowledge and learn from mistakes and near misses. At the same time patients and families need to embrace their important role in making sure they receive a timely, carefully considered and accurate diagnosis in every health-care encounter.
Dan Berg lives in Minneapolis and is an advocate for patient safety.
