Diagnostic Errors Cause of Patient Safety Problems

Errors related to missed or delayed diagnosis are frequently a cause of patient injury and therefore an underlying cause of patient safety related events. Autopsy analysis spanning several decades show error rates at four to 50 percent, according to an article released today by the Pennsylvania Patient Safety Authority and published in its September Pennsylvania Patient Safety Advisory.

Diagnostic error is a diagnosis that is missed, incorrect, or delayed as detected by a subsequent definitive test or finding. Not all misdiagnosis results in harm and harm may be due to either disease or intervention.

Diagnostic errors are encountered in every specialty and are generally lowest (less than five percent) for certain specialties that rely on visual pattern recognition and interpretation (e.g., radiology, pathology, dermatology). Error rates in specialties that rely more on data gathering and the combination of different elements for a conclusive diagnosis are higher (10 to 15 percent).

"Diagnostic errors are often the first or second leading cause of medical malpractice claims in the United States," Dr. John Clarke, clinical director of the Pennsylvania Patient Safety Authority said. "They account for twice as many ongoing and settled claims as medication errors."

Clarke added that studies have also shown that both cognitive errors and system design flaws contribute to diagnostic error.

"Communication issues, along with reasoning errors and system breakdowns all contribute to diagnostic errors," Clarke said. "The Advisory article reviews the common causes of diagnostic error and gives healthcare providers and patients information on how they can decrease the risk of a diagnostic error and thereby increase patient safety."

The Authority reviewed 100 events related to diagnostic error between June 2004 and November 2009 in an effort to determine if there were system solutions to diagnostic error, or if diagnostic error was so closely connected to doctors' cognitive processing that system solutions were not possible. Examples of reports were found in the Pennsylvania Patient Safety Reporting System (PA-PSRS) by searching on terms such as delayed diagnosis, wrong diagnosis, missed diagnosis, misdiagnosed, failure to diagnose, failure to treat and medical follow-up. Some of the sample reports with possible cognitive error examples include:

To read the full article please visit Patient Safety & Quality Healthcare http://www.psqh.com/news/current-news/608-patients-are-injured-due-to-missed-or-delayed-diagnosis-analysis-shows.html