Adding Up Diagnosis Errors

April 22, 2013

22 Apr (WALL STREET JOURNAL) – Mistakes diagnosing patients are the most common, costly and dangerous errors made by doctors in the U.S. and result in permanent injury or death for as many as 160,000 patients annually, a new study found.                                                                                                                                        By  LAURA LANDRO 

Researchers at Johns Hopkins University looked at more than 350,000 malpractice claims over 25 years. They found that diagnostic errors—defined as missed, wrong, or delayed diagnosis—accounted for nearly 29% of claims, more than other categories such as treatment, surgery or medication. Diagnostic errors made up the biggest share of claim payments at 35.2% of total payments, or $38.8 billion, adjusted for inflation, from 1986 to 2010. They resulted in death in more than 40% of claims.

MISSED SIGNALS

Top five patient problems that doctors failed to diagnose correctly in a 2013 study of errors in primary-care visits:

  • Pneumonia
  • Worsening congestive heart failure
  • Acute renal failure
  • Cancer
  • Urinary tract or kidney infection

SOME LEADING REASONS FOR ERRORS:

  • Breakdown in communication during patient’s initial visit to doctor
  • Dooctor fails to refer patient to a specialist
  • Patient doesn’t provide adequate medical history
  • Doctor fails to follow up with patient after diagnosis
  • Diagnostic tests aren’t interpreted correctly

Source: JAMA Internal Medicine; Houston VA/Baylor College of Medicine

The study, published online Monday in the journal BMJ Quality and Safety, underscores the trade-offs in the diagnostic process: More medical tests generally improve detection, but they can also increase costs, harm patients, and produce false positives. Fear of a malpractice suit for missing a diagnosis is a major driver behind “defensive medicine,” the researchers note.

“There isn’t going to be one magic bullet to solve the problem of diagnostic error, but we can start by consistently monitoring and measuring it,” says David Newman-Toker, lead author of the study and an associate professor of neurology at Hopkins.

While hospitals report on quality measures such as cardiac bypass surgery outcomes, diagnostic errors aren’t reported or measured by federal or private quality programs.

“No one wants to tell anyone they are missing 10% to 20% of their diagnoses,” Dr. Newman-Toker says.

Hardeep Singh, a researcher at Michael E. DeBakey VA Medical Center, Houston, Texas and assistant professor of medicine at Baylor College of Medicine who has wrote several studies on diagnostic error, says that while the Hopkins study confirms previous research, malpractice data provide a limited picture.

Often, a diagnosis “evolves over time” so a patient’s problem might not be clear from initial symptoms, Dr Singh says, but that isn’t necessarily a diagnostic error.

Dr. Singh and other researchers are studying how to better define and measure errors and what strategies best prevent them, such as using electronic health records to track patient test results and helping doctors with software that suggests an alternative diagnosis based on symptoms.

The Johns Hopkins researchers acknowledged that claims data are imperfect: Some claims paid may not be associated with true error, and the vast majority of true errors never result in a claim. But prior studies show that paid claims are mostly not frivolous and malpractice data can be an indicator of the prevalence and seriousness of adverse events. The study compared closed paid claims from the National Practitioner Data Bank, which was established by federal law in 1986 and keeps an electronic repository of all malpractice payments.

Researchers found roughly equal numbers of lethal and nonlethal mistakes. Previous estimates of hospital deaths from diagnostic error were as high as 80,000 per year, which suggests that total diagnostic errors could be twice that level, and “it is probably a lot higher than that,” Dr. Newman-Toker says.

The study found that the highest payments were for severe, permanent neurological damage. While the data didn’t show the cause of the damage, Dr. Newman-Toker estimates there are 100,000 missed strokes annually in the U.S.

“There is probably a huge amount of unmeasured disability due to diagnostic error” with strokes, he says.

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