by Ted J. Clarke, MD, Chairman & CEO, COPIC Insurance Company
Featured in the January/February 2016 Colorado Medicine.
Diagnostic errors were pushed to the forefront last year when the National Academy of Medicine (formerly known as the Institute of Medicine) released its Improving Diagnosis in Health Care report. The report highlights key factors that contribute to these errors and establishes a solid foundation of data to draw upon. It also illuminates the scope of this issue, estimating that 5 percent of U.S. adults who seek outpatient care each year experience a diagnostic error.
An important observation from the report is that diagnostic errors are not always due to human errors, but, rather, often occur because of errors in the health care system. “The complexity of health and disease and the increasing complexity of health care demands collaboration and teamwork among and between health care professionals, as well as with patients and their families,” said John R. Ball, chair of the Committee on Diagnostic Error in Health Care, in the report’s preface.
Several of the recommendations outlined reflect efforts that COPIC has engaged in for years. For example, the report calls for the adoption of communication and resolution programs to enhance the disclosure process with patients. Our 3Rs Program, launched in 2000, is considered an industry benchmark and continues to support resolutions between patients and physicians while attempting to preserve these relationships. The report also highlights the need to enhance education and training in the diagnostic process for health care professionals. During the last decade, COPIC has developed courses and seminars that specifically examine diagnostic errors to support learning that leads to improved outcomes.
COPIC’s Practice Quality (PQ) Review is another valuable resource that helps medical practices address diagnostic errors. These on-site reviews are conducted by specially trained nurses who use Level One Guidelines developed by COPIC. The guidelines are determined by actual medical liability claims and incident reports in order to recognize high-risk areas. Through these thorough and objective reviews, medical professionals work closely with COPIC to identify areas for improvement, address challenges unique to a particular practice and integrate best practices.
The report notes that “because the diagnostic process is a complex, team-based, iterative process that occurs over varying time spans, there are numerous opportunities for failures.” To better understand why these failures happen, we need to look at the diagnostic process and examine why certain steps never occur or are being done incompletely or incorrectly (accuracy), as well as what may be causing meaningful delays in taking a step (timeliness).
PQ Reviews serve as an audit to help medical practices evaluate steps in their own internal systems. We know that ordering tests and communicating results to the medical team and patients is an area where problems can arise. Therefore, the guidelines used during a review include a list of “best practices” and “things to avoid” so there are standardized systems in place for the following.
- Patient follow-up and consultation tracking.
- Test tracking.
- Reviewing/signing of incoming reports and correspondence.
- Patient notification of test results.
PQ Reviews also focus on medical records and documentation. An accurate clinical history and gathering appropriate patient information is crucial in the diagnostic process. The reviews provide guidance on what patient details to collect, how to include these in the record, and documentation standards that ensure others interpret information correctly. This includes the following areas.
- Allergies and adverse drug reactions.
- Current problem list/medical history.
- Current medication list.
- Vital sign documentation in acute illness.
While diagnostic errors are an issue that the health care community was aware of, this report tackles the subject from a fresh, comprehensive perspective that adds clarity as to why they occur. It provides informative data, raises new questions and promotes discussions on how to improve patient safety. And for COPIC, it reminds us of the role we can play in offering resources and guidance that help medical professionals learn from past events and improve their future diagnoses.
A copy of the Improving Diagnosis in Health Care report can be downloaded at www.nap.edu/catalog/21794/improving-diagnosis-in-health-care.