I can’t be 100% certain, but I’m betting my next squirt of nitro spray that the Emergency Department physician who misdiagnosed me with acid reflux and sent me home despite my textbook heart attack symptoms (central chest pain, nausea, sweating and pain down my left arm) did NOT voluntarily report his diagnostic error to his supervisor or to anybody else after I was correctly diagnosed much later by a different emergency doc.
I’m also betting that he, being a smart person with the letters M.D. after his name, had a pretty good idea of the definition of the term “diagnostic error” (even I know that this means an inaccurate or delayed medical diagnosis). Second, he was very likely fully knowledgeable about how diagnostic errors can hurt patients like me. And thirdly, it was probably not too hard for him to assess the precise outcomes of such an error (patient sent home from Emergency despite textbook cardiac symptoms, thus delaying appropriate treatment for what doctors still call a widowmaker heart attack).
Yet those three excuses are what we’re offered to explain why mandatory reporting of diagnostic errors is not among the eight key recommendations in the Institute of Medicine’s new report called Improving Diagnosis in Healthcare. (You can order a hard copy of this impressive 346-page IOM report, read the report online free, or check out the 4-page Report In Brief version).
At least twice during the report launch briefing event I watched live on my laptop screen this week, I heard this excuse voiced by the committee chair:
“Now is not the right time for mandatory reporting of diagnostic errors.”
The full report explains this troubling stance by claiming three things:
- there had been no agreed-upon definition of diagnostic error prior to this report
- there is not enough data on diagnostic error
- it is hard to measure outcomes to collect such data
But my question to the IOM committee that came to this conclusion is this:
If now is “not the right time for mandatory reporting”, when might that right time be?
The impact of getting a wrong diagnosis is staggering. The report warns, for example:
“Diagnosis – and, in particular, the occurrence of diagnostic errors – has been largely unappreciated in efforts to improve the quality and safety of health care.
“The result of this inattention is significant: most people will experience at least one diagnostic error in their lifetime, sometimes with devastating consequences.
“Urgent change is warranted to address this challenge.”
“Urgent change”, however, does not apparently include a recommendation to start requiring health care professionals to report diagnostic error.
“Voluntary reporting efforts should be encouraged and evaluated for their effectiveness.”
Allow me to translate that for you, dear reader:
“Somebody should do something about this. Some day. Really . . .”
The IOM report politely observes that, despite numerous calls for change, “efforts to improve voluntary reporting and analysis at the national level have been slow”.
Why not, then, a strong recommendation for mandatory reporting of diagnostic errors, and why not now?
Many studies have been published on the question of why health care professionals all over the world have been so “slow” to voluntarily come forward and report their diagnostic errors (1). For example:
“The main reasons for not reporting were fears that junior staff would be blamed, high workload, and the belief (even when an incident was designated as reportable) that the circumstances or outcome of a particular case did not warrant a report.“
A study(2) on under-reporting of adverse medical events blamed powerful disincentives to impose mandatory reporting. (Translation: “You can’t make me!”)
We already know that complex non-medical industries have long had effective incident-reporting systems in place to protect the public, although in the early days of mandatory reporting, one can imagine that industry types also protested: “Oh, now is not the right time!” One study(3) compared reporting of misdiagnoses and other adverse medical errors to other real-world expectations in the field of public safety, concluding:
“The situation is like that of the field of injury control, where until there was focused public attention and demand for action on injuries and their prevention, injury remained a neglected health problem.”
That shift towards mandatory reporting when bad things happen in order to protect public safety explains why we no longer have voluntary hard hat usage on construction sites, or voluntary speed limit rules on our highways, or voluntary safety checklists by airline pilots before takeoff.
Yet when it comes to making our medical care safer, we are being told that now is somehow not quite the right time for mandatory reporting of diagnostic errors.
The IOM’s puzzling reluctance to walk the bold talk seems to contradict its own 1999 To Err is Human report on preventable medical errors(4).
In this groundbreaking report, the IOM emphasized the importance of reporting errors, using systems to “hold providers accountable for performance,” and “provide information that leads to improved safety.”
That 1999 report also referred specifically to both serious errors that resulted in deadly outcomes, as well as three types of potentially serious errors that (as in my own misdiagnosed heart attack) are caught in time to ward off deadly outcomes. Committee authors insisted at that time that the reporting of potentially harmful errors that were intercepted before harm was done, errors that did not cause harm, and near-miss errors is “as important as reporting the ones that do harm patients.”
So let’s put a human face to that reality.
Let’s imagine that the hospital that had sent me home with an acid reflux misdiagnosis had in place a policy that suggested its staff could (if they felt like it) voluntarily report such a diagnostic error as soon as that initial error became known to them (i.e. when the patient was later readmitted to the E.R. for a correct diagnosis/treatment, or was found dead at home of a heart attack).
But hey! I’d survived that heart attack despite being misdiagnosed during my first trip to the E.R. I hadn’t died. I was still alive. So really, what’s the harm? What’s to prevent Emergency personnel from deciding that the circumstances and outcome of my case did not even warrant a report? Case closed.
That diagnostic error never happened, because it was never reported.
Now let’s imagine that a mandatory reporting protocol for diagnostic error had been in place that day (regardless of circumstance or outcome). As soon as the Emergency medicine personnel during my second E.R. visit realized that I’d been previously misdiagnosed, a mandatory protocol would have helped staff report that this patient had been sent home earlier because of a diagnostic error.
Mandatory reporting of diagnostic error is all about specifically attempting to safeguard the health of future patients.
Had that hospital endorsed mandatory reporting, it would have meant that the next time my ER physician has another middle-aged woman presenting with significant heart attack symptoms but “normal” cardiac tests (a surprisingly common occurrence for female heart patients), he just might remember my own case and hesitate before sending that woman home, just another middle-aged woman making a big fuss over a little indigestion.
This focus on preventing future events happens in exactly the same fashion that workplace safety, highway safety, and aviation safety protocols that enforce mandatory reporting of errors are seeking to protect future victims of those errors, too.
How can anybody, anywhere claim that patients do not deserve the same attempts at protecting us, too?
And what can patients do to help protect ourselves from being the victims of diagnostic error? Researcher Dr. Hardeep Singh, one of the physicians who served as an expert reviewer on the IOM report, had this suggestion during a Wall Street Journal interview:
“They could be strong partners with their doctors. Patients should always check on their own test results, regardless of whether they have heard back from their doctor or not. So no news is not necessarily good news.
“Second opinions are often suggested as potential interventions to reduce misdiagnosis. In one of our studies, second opinions changed diagnosis around 15% of the time and treatment about 37%. That’s a pretty big impact.”
Meanwhile, as the award-winning ProPublica journalist Marshall Allen (most recently of Surgeon Scorecard project fame) warned his audience at Stanford University’s Medicine X conference this past week:
“Until you start measuring something, you can’t improve it.”
I was interviewed by the IOM during this summer’s production of a short video (6:49) that accompanied the launch of their new report, Improving Diagnosis in Healthcare. The video features three people affected by diagnostic error; mine was the first patient story in the video (note that the video was unfortunately edited to make it appear that my only heart attack symptom was “pain down my left arm”, which is inaccurate; other symptoms included textbook central chest pain, nausea and sweating). Although feedback about this video project has been warmly positive, I’d like to acknowledge the American College of Emergency Physicians and their Twitter followers, some of whom objected to several parts of the IOM video. Some felt defensive about what they interpreted as blaming Emergency Medicine for diagnostic error; they claimed that diagnostic error is mostly due to all those other medical specialties (like radiology). For women experiencing heart attack, however, E.R. staff are indeed the gatekeepers between us and appropriate cardiac care.
Q: Are there good reasons for NOT recommending mandatory reporting of diagnostic errors?
- “It’s not your heart. It’s just _____” (insert misdiagnosis)
- Misdiagnosis: is it what doctors think, or HOW they think?
- Seven ways to misdiagnose a heart attack
- Stupid things that doctors say to heart patients
- Misdiagnosis: the perils of “unwarranted certainty”
- Cardiac gender bias: we need less TALK and more WALK
- Unconscious bias: why women don’t get the same care men do
- When you fear being labelled a “difficult” patient
- The sad reality of women’s heart disease hits home
- How can we get heart patients past the E.R. gatekeepers?