I first became intrigued by issues such as medical mistakes and diagnostic error after I was misdiagnosed in mid-heart attack (“You are in the right demographic for acid reflux!”) and then sent home from Emergency – despite textbook cardiac symptoms of central chest pain, nausea, sweating and pain down my left arm. . I’m no doctor, but even I knew at the time that left arm pain is not a symptom of indigestion. But I felt so embarrassed for making a fuss over “nothing” that I couldn’t get out of there fast enough. By the time I was desperate enough to finally force myself to return to the same Emergency Department, I could not walk more than five steps, and I knew that the doctor who had cheerfully misdiagnosed my symptoms had been horribly wrong. My “widow maker” heart attack was appropriately diagnosed (this time, by a different Emergency doc). Ever since then, I have been asking questions. Questions like, why are women like me significantly more likely to be misdiagnosed in mid-heart attack compared to our male counterparts? . Why are ambulances transporting female heart patients to the hospital less likely to use flashing lights and sirens than they do for male heart patients? . Why have cardiac diagnostic tests, drugs and procedures been largely designed and researched for the past four decades on (white, middle-aged) men – yet women are still not equitably represented in clinic trials?(1) . We have few answers to most questions (although the history of women’s health care suggests that, as in other areas of our culture, implicit bias against female patients is pervasive). . Here’s an example of this implicit bias, from cardiac researcher Dr. Karin Humphries in Vancouver, whose studies suggest a significant problem with the routine blood test for the cardiac enzyme called troponin – typically a reliable marker for heart muscle damage caused by a heart attack.(2) But the commonly used troponin threshold in this test is based on a level that’s considered appropriate for men, but may be set too high for women – whose blood tests would then be interpreted as “normal”. Dr. Humphries suggests that “setting a lower female-specific troponin threshold would improve the diagnosis, treatment and outcomes of women presenting to the Emergency Department.” . This begs another question: how many women like me have been refused cardiac treatment because our troponin blood tests appeared to be “normal” – no matter how severe their cardiac symptoms were? . To my knowledge, there is no requirement for mandatory reporting of diagnostic error in most healthcare systems – including here on the west coast of Canada. What stunned me most was learning that, because such errors are not reported, it means they never happened. If I had died after being turned away that day, my death certificate would have almost certainly read, under cause of death, “myocardial infarction” (heart attack). But that cause of death would have been wrong, as I wrote here:
” If patients are looking for a doctor who has never made a mistake, they simply won‘t find one.”
. Physicians who argue against mandatory reporting of misdiagnosis seem united in a vague unwillingness to see this as a public safety issue. For example, even though the authors of the landmark Institute of Medicine report in 2015 called Improving Diagnosis in Healthcare concluded: “Urgent change is warranted to address this challenge”, they politely backed off from recommending mandatory reporting. Instead, here’s how the report’s committee chair responded to repeated media questions at the report’s official launch event in Washington, DC::
“The actual cause of my death would have been that I was misdiagnosed during a heart attack, denied appropriate care, and sent home from the Emergency Department. . “Had a death occurred, the fact that I’d been earlier misdiagnosed in the same hospital and sent home might never have been reported, never reviewed at hospital rounds, never discussed with the medical director, never used as an important case study for med students, never considered as a teaching tool that might help prevent this type of cardiac misdiagnosis from happening to other women in the future – and certainly never recorded on a death certificate as the cause of my death. . “And what a lost opportunity that would have been.”
How “effective” do you think these “voluntary reporting efforts” are, years later? If voluntary efforts were actually effective, we would still have voluntary hard hat usage on construction sites, or voluntary speed limit laws on our highways, or voluntary safety checklists by airline pilots before takeoff. Studies (3,4) on the under-reporting of adverse medical events have blamed “powerful disincentives to impose mandatory reporting”. (Translation: “You can’t make me!”) The healthcare field is alone among workplaces in that, when bad things happen to their end users, the knee jerk response is to hope that they’ll just go away quietly. See also: Saying the Word “Misdiagnosis” is Not Doctor-Bashing Other occupations, by comparison, routinely require incident reports whenever a critical incident occurs on the job that has involved harm, potential harm or death. This is a public safety issue, and addressing it is considered the prudent path to help prevent similar harms in the future. Ignoring what has happened is not prudent. Healthcare professionals may fear that reporting errors means blame and punishment, not an opportunity to learn or to protect future patients from preventable harm. As HR consultant Michael Tims tells his clients:
“ Now is not the right time for mandatory reporting of diagnostic errors. Voluntary reporting efforts should be encouraged and evaluated for their effectiveness.”
“The only thing people learn from being blamed is to become better at hiding their mistakes.”Sometimes that fear might be justified – especially when individual healthcare professionals are sued or criminally charged for tragedies that can arguably be due to the way healthcare systems work. So individuals working hard on the front lines can worry that blame will fall upon them for harms that may be more accurately inevitable results of systemic issues. Here’s an example of a hospital environment designed to cause errors, according to Emergency doc Dr. Terry Fairbanks, a human factors engineer-turned-physician who has studied human errors in medicine for decades. He describes how errors can happen in the case of a hospital nurse who gives medications to patients earlier or later than ordered:
“ These errors can happen because in the 11 a.m.-1 p.m. time frame required to give all noon meds, for example, the nurse cannot possibly do it. From an industrial design perspective, the nurse is being forced to find a shortcut.”Yet if something tragic happens as a direct result of that nurse’s “shortcut”, the system itself won’t be sued, fired or criminally charged with negligence – but that individual nurse might be. Dr. Fairbanks (a Professor of Emergency Medicine at Georgetown University and Founding Director of the National Center for Human Factors in Healthcare) was first known as an expert in human performance, specifically in how to change systems to make that performance safer by addressing human errors and creating a culture of accountability. But health care, he warns, does something that other complex high-risk industries don’t do anymore when it comes to errors:
. It turns out that industries learn from each other’s experience in reducing workplace harm. Their singular focus on preventing future harm happens in the same fashion as workplace safety, highway safety, nuclear energy safety or aviation safety protocols that embrace mandatory reporting of critical incidents in order to help track these incidents. How can anybody, anywhere continue to insist that patients do not deserve the same efforts at protecting us, too? The Doctors Association of U.K. (DAUK) has launched #LearnNotBlame, a campaign they hope will result in what they call a “just culture” in Britain’s National Health Service. U.K. neurologist Dr. Jenny Vaughan, who in 2018 was awarded the British Medical Journal (BMJ) award for ‘speaking truth to power’, advocates for improvements to patient safety by working with DAUK. As she says,
“We keep focusing on individual performance. We need to change our focus to reducing harm, not just reducing error.
“In the 1970s, when we were trying to reduce human error in aviation and we were using the nuclear energy industry as our model, aviation experts told us, ‘It’s different – we’re not the same, you can’t apply this stuff to us!’ ”
” Health care needs an open and transparent culture where harm is minimized by learning from mistakes. Patient safety should always come first. We need to bring in a truly just culture so that all errors are discussed openly.”Trying to pretend that errors which cause harm are not happening is neither open nor transparent.
(1) Editorial, The Lancet, “Cardiology’s Problem Women”; Volume 383, Issue 10175, p959; March 9, 2019.
(2) Zhao Y, Izadnegahdar M, Humphries KH et al. “High-Sensitivity Cardiac Troponin – Optimizing the Diagnosis of Acute Myocardial Infarction/Injury in Women (CODE-MI)”. Am Heart J. 2020 Nov; 229:18-28.
(3) Vincent C. “Reasons for not reporting adverse events: an empirical study. ” J Eval Clin Pract. 1999; 5:1–9.
(4) Paul Barach et al. “Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems.” BMJ. 2000 Mar 18; 320(7237): 759–763..
. ♥ NOTE FROM CAROLYN: I wrote much more about patient safety in my book “A Woman’s Guide to Living with Heart Disease“ (Johns Hopkins University Press, 2017). You can ask for this book at your local bookshop, or order it online (paperback, hardcover or e-book) at Amazon, or or order it directly from my publisher Johns Hopkins University Press (use their code HTWN to save 30% off the list price).
Q: Are there any good reasons for NOT recommending mandatory reporting of diagnostic errors?