Frontline strategies to reduce misdiagnosis in hospitalized patients

While recent studies show diagnostic errors are common, researchers find diagnostic error to be a very complex topic where few practical and proven solutions exist for frontline clinicians. In an effort to advance knowledge in this area, researchers from Baylor College of Medicine, the Michael E. DeBakey Veterans Affairs Medical Center and the Institute of Medical Education Research Rotterdam, Erasmus MC propose a pragmatic framework of strategies to reduce errors of diagnosis in hospitalized patients in a paper published today in Annals of Internal Medicine.

"National policymakers are stepping up patient safety efforts and just recently the Centers for Medicare and Medicaid Services awarded nearly $350 million in funding to reduce hospital-acquired conditions and readmissions. However, misdiagnosis reduction generally gets relegated to the sidelines," said Dr. Hardeep Singh, associate professor of medicine at Baylor and chief of the Health Policy, Quality and Informatics Program at the Houston VA Center for Innovations in Quality, Effectiveness and Safety. "In this paper we highlight practical recommendations and opportunities to reduce errors of diagnosis in hospitalized patients."

While work in the outpatient setting estimates that 1 in 20 U.S. adults are misdiagnosed annually, researchers don't really know how common these errors are in U.S. hospitals, Singh said. Some data is available from autopsies, but they are often not performed.

In order to devise practical strategies to reduce errors in hospital medicine, Singh and his colleague, Dr. Laura Zwaan, used insights from error analysis to identify improvement opportunities within each of the five dimensions of diagnosis.

The five dimensions and selected examples from their list of suggestions are as follows:

1. Patient-physician encounter: allocate time to effectively communicate with patients; seek "cognitive support" to help decision-making in cases of uncertainty
2. Performance and interpretation of diagnostic tests: collaborate in person with lab professionals and radiologists to interpret complex test results or in cases of difficult diagnosis
3. Follow-up and tracking of diagnostic information over time: do not overlook past diagnostic data during the current hospitalization; clarify responsibilities of follow-up of abnormal test results
4. Subspecialty consultation-related communication and coordination: use direct verbal communication when making critical decisions; ensure everyone on the team is on same page about diagnosis when multiple consultants are involved
5. Patient-focused strategies: encourage proactive patient and family participation in the diagnostic process; encourage patients to look at their own medical notes to find inconsistencies

"Our suggested strategies are based on literature and experience and not necessarily interventions evaluated in trials; this is a complex, multifaceted and difficult-to-measure problem," Singh said. "Many improvement strategies were suggested based on known areas of vulnerability from prior research. For example, the post-discharge time period is high-risk for error so we suggest encouraging patients to be proactive in ensuring that the post-discharge diagnostic evaluation is reviewed and pursued by outpatient physicians in a timely manner."

Singh pointed out that while this paper focuses on the hospital setting, many strategies are broadly applicable to other settings.

Singh also mentions that the time appears to be ripe to address measurement challenges of diagnostic errors. Recently, the Agency for Healthcare Research and Quality, which along with the Department of Veterans Affairs funds Singh's research, hosted a Research Summit on Improving Diagnosis in Health Care where Singh co-led a panel discussion on measurement. In addition, the National Quality Forum just announced it will convene a committee to develop a framework for measurement of diagnostic accuracy.

"It is an opportune time for researchers to translate emerging scientific evidence to clinical practice and work collaboratively with healthcare organizations, national policy makers and patient advocates to improve the safety of diagnosis," Singh said.