Bringing diagnosis into the quality and safety equations.

CASES OF DELAYED, MISSED, AND INCORRECT DIAGnosis are common, with an incidence in the range of 10% to 20%. Some errors in diagnosis stem from mistakes in the interpretation of diagnostic tests. For example, pathology, radiology, and the clinical laboratory each have error rates of 2% to 5%. Superimposed on these testing errors are the ubiquitous system-related errors encountered in every health care organization, as well as cognitive errors caused by faulty clinical reasoning. Diagnostic errors do not occur only in connection with unusual conditions but span the breadth of clinical medicine, from rare disorders to commonplace ones like anemia and asthma. Most diagnostic errors are either inconsequential or discovered in time, but others are not. Based on the findings from large autopsy series, Leape et al estimated that diagnostic error accounts for 40 000 to 80 000 deaths per year, and the number of patients who are injured must be substantially higher. In a recent survey of more than 6000 physicians, 96% felt that diagnostic errors were preventable. How is it then that improving diagnosis goes largely unrepresented in the current quality framework? The recently proposed National Quality Strategy focuses almost exclusively on management, as do the proposed “pay-for-performance” measures and those presently being publicly reported. As Nuland observed, diagnosis is “ . . . the most critical of a physician’s skills. It is every doctor’s measure of his abilities; it is the most important ingredient in his professional self image.” Patients undoubtedly want their physicians to be accurate diagnosticians too. Yet diagnosis has been omitted from the quality and safety equations. Diagnosis apparently gets overlooked in most efforts to ensure quality and safety. In the seminal Institute of Medicine report To Err Is Human, the phrase medication error is used 70 times while diagnostic error occurs twice. Although there are many reasons for this omission, difficulty understanding and measuring diagnostic errors is certainly part of the answer. Another major factor involves the absence of ownership: in the quality and safety family, diagnostic error is essentially an orphan. Health care leaders assume their physicians should be responsible for ensuring reliable diagnoses, but most physicians seem to believe they are doing just fine. Through malpractice suits, physicians are well aware of diagnostic error, but there is a general tendency to perceive that such errors are made by someone else, someone less careful or skillful. Moreover, whereas errors such as wrong-site surgery and wrong-dose medication errors seem amenable to systems solutions (time-outs, computerized order entry, etc), diagnostic errors seem intensely personal: the “system” appears to be the physician, and his or her own knowledge, skills, values, and behaviors. The absence of diagnosis-related quality measures has had several consequences. The lack of interest and emphasis has translated into a similar level of apathy within health care organizations. We are unaware of any health care organization that is currently collecting specific data on diagnostic error or engaged in a system-wide campaign to decrease the frequency or consequences of diagnostic error. Without data on such errors, there is no clear motivation to improve the diagnostic process and no way to measure progress. Moreover, with so much focus being placed on improving quality and safety in treatment-related areas, the relative inattention to diagnosis has consequences: resources and attention that could be used to improve diagnosis are devoted instead to the already-overrepresented management issues. Not only is diagnosis critically important to patients, but improving diagnostic skill lies at the heart of efforts to rein in escalating costs of health care. Costs related to diagnostic testing are increasing faster than any other component of health care expenditures. The ABIM Foundation’s recently launched “Choosing Wisely” campaign focuses on using the most appropriate diagnostic strategies, an effort that could save billions of dollars. Additional savings could be found in reducing the harm caused by diagnostic errors; the magnitude of these costs must be substantial but have never been estimated.