Q&A: Learning from the IOM report on diagnostic errors

The Institute of Medicine (IOM) published a report last week about reducing diagnostic errors in healthcare.

The report, written by the IOM’s Committee on Diagnostic Error in Health Care, detailed specific ways providers can work to improve their diagnostic process, including: increased cooperation among healthcare professionals, improved education and training for all healthcare professionals, and cultures that put more value in feedback, effective communication and supporting one another. A summary of the report, and the report in its entirety, can be found on the IOM’s website.

Anupam B. Jena, MD, PhD, associate professor of health care policy at Harvard Medical School, worked on the report as a member of the Committee on Diagnostic Error in Health Care. He spoke with RadiologyBusiness.com to discuss the report’s findings.

RB: Can you explain the overall  importance of improving diagnosis and reducing diagnostic errors?

Jena: The issue of patient safety and quality of care is relatively new—and by “relatively,” I mean somewhere in the order of 25 years or so—and most of the emphasis has been placed on errors not of diagnosis, but procedural errors, medication errors, and other system-level errors.

That is, in some sense, surprising, because in order to treat a patient correctly, you have to have the correct diagnosis. It’s really not clear why errors in diagnosis have been on the back burner for so many years. Perhaps the most important reason is that it’s very difficult to measure diagnostic errors. The factors that contribute to diagnostic errors are also very challenging to define and measure.

There are clearly system-level errors that lead to diagnostic errors, meaning improvements in certain systems and processes could potentially reduce diagnostic errors. There has also been the belief that diagnostic errors owe to cognitive pitfalls of physicians, and those are harder things to address and fix.

RB: The report mentions improved communication and teamwork between (1) healthcare professionals and also (2) the patients and their families. Why is this so important?  

Jena: Teamwork is critical.

Consider, for instance, that physicians routinely take board certification and other exams. Suppose one physician gets 70 percent of the questions correct, and another physician gets a different 70 percent of the questions correct. If you put those two physicians together, and for each question, say, “I’m going to count this as correct if at least one of the two physician gets it correct,” what you will likely find is the pair would get 90 percent of the questions right. That’s a complex way to say that two minds are better than one. It makes a lot of sense that teamwork across healthcare professionals would have the potential to deliver better outcomes.

What is less obvious, but I think is a critical feature of the report, is that patients themselves are the most important part of the team. At the end of the day, patients hold the answers to a lot of questions physicians may have. The diagnostic process and treatment process are extraordinarily complex, so having someone who is living through those processes in real time is critical to making sure you have a diagnosis correct. It’s the job of the healthcare system and the provider to call a patient and ask, “are you getting better?” The role of the patient is to call the doctor and say, “I’m not getting better ... something doesn’t feel right.”

When both parties are aligned, I think you have the potential to dramatically reduce diagnostic errors.

RB: The report says a culture must be established that supports the diagnostic process. What does such a culture look like?

Jena: I think there are several elements to that culture. The first is a “provider culture,” and the idea there is that diagnostic errors are going to happen, but how do we prevent them from happening? There has to be a culture that says, “what can we do better to reduce diagnostic errors?”

The second element is, once we recognize that diagnostic errors do occur, how do we learn from those? Not only should the person who is responsible for the error learn from the mistake, but others should learn about those mistakes as well.

Third, all of this has to be in an environment where those errors are forthcoming and people feel comfortable having this information known by others. That transparency and learning is an important aspect of culture, and we are moving toward that.

The final element of culture is to recognize the important role of the patient. Patients and providers together can learn from mistakes and make other patients better off.

RB: If healthcare providers read about this report and want to get started immediately on improving in these areas, what’s something they can do today?

Jena: I think the most important thing a provider organization could do would be to think about how to measure the extent of the problem. Without knowing how big of a problem diagnostic error is in your own organization, it’s impossible to address it.

The next step is to then figure out, “how do we set up a process to reduce diagnostic errors?”