Latest IOM Quality Chasm Series Report Targets Diagnostic Errors

What the Institute of Medicine (IOM) did for the discussion of medical errors in its To Err is Human report, it now seeks to do for diagnostic errors with the latest installment of its Quality Chasm Series titled Improving Diagnosis in Health Care. Estimating that most individuals experience at least one diagnostic error at some point in life, and 5 percent of adults experience an error each year, the report asserts that "[i]mproving the diagnostic process is not only possible, but also represents a moral, professional, and public health imperative."

"Diagnostic errors are a significant contributor to patient harm that has received far too little attention until now. I am confident that Improving Diagnosis in Health Care, like the earlier reports in the IOM series, will have a profound effect not only on the way our health care system operates but also on the lives of patients," said Victor J. Dzau, president of the National Academy of Medicine, in a statement announcing the release of the report. The Institute of Medicine is a unit of the newly formed National Academies of Sciences, Engineering, and Medicine.

Analysis reveals causes for diagnostic errors
The report defines diagnostic errors, focusing on the patient's perspective, as either the failure to establish an "accurate and timely explanation" of the patient's health issue or failure to "communicate that explanation to the patient." Predicting that diagnostic errors "will likely worsen as the delivery of health care and the diagnostic process continue to increase in complexity," the expert committee convened for the report concluded the following causes contribute to diagnostic errors:

• insufficient communication between providers, patients and families,
• lack of support for the diagnostic process within the health care system, and
• "a culture that discourages transparency and disclosure of diagnostic errors."

Recommendations emphasize collaboration, communication
The report sets eight goals for improving diagnostic processes and reducing errors. Overall, those goals focus on themes such as teamwork and collaboration, integrating the patient into the process and providing a forum for identifying, discussing and learning from errors.

"Diagnosis is a collective effort that often involves a team of health care professionals—from primary care physicians, to nurses, to pathologists and radiologists," said the committee's chair, John R. Ball, executive vice president emeritus of the American College of Physicians in a statement. Explaining that diagnostic decisions can't always be made by one lone provider and human error isn't always the source of diagnostic errors, Ball asserted "[t]o make the changes necessary to reduce diagnostic errors in our health care system, we have to look more broadly at improving the entire process of how a diagnosis [is] made."

Thus, the committee's recommendations promote collaboration among providers in the diagnostic process and more emphasis on patient involvement. To support this process, the committee calls for payment models that move away from fee-for-service and provide payment to pathologists for consultation with treating physicians about diagnostic testing for patients.

As with the To Err is Human report, this latest report in the Chasm series also promotes a "non-punitive culture" where performance issues and disclosure of errors can be openly discussed. The committee noted that to support this level of transparency, changes are needed in the liability system. Finally, the committee challenged federal agencies to set a research agenda regarding the diagnostic process and diagnostic errors by the end of 2016.

The report was sponsored by the Agency for Healthcare Research and Quality, Centers for Disease Control and Prevention, College of American Pathologists, American Society for Clinical Pathology and several other organizations and foundations.

Industry reacts positively to recommendations
Reaction in the industry to the report has been positive—particularly with regard to the need for collaboration among professionals. An AACC statement identifies the report's call for collaboration among health care professionals as "one of the report's most powerful recommendations" and "one that deserves more prominence." "The field of diagnostic testing is growing at an incredible rate, with recent advances in DNA, RNA, and protein testing adding more complexity to an already enormous catalogue of available tests." Thus, AACC says laboratory professionals are "critical" to helping determine the right tests for patients and interpreting and using the results "appropriately."

The College of American Pathologists, which also sponsored the report, similarly issued a statement emphasizing its support for the need for "collaboration among pathologists, other diagnosticians, and treating health care professionals" and new payment methodologies that support such collaboration. "Beyond regulation, clinical quality and the avoidance of error requires a team based approach to diagnosis that the report encourages and that we wholeheartedly support."

A Perspective published in the New England Journal of Medicine, says now is the time to be focusing on the diagnostic process and effecting change: "we would argue diagnostic errors are clinically and financially more costly today than every before" and "[a]dvances in HIT and big data offer new instruments for measuring and reducing diagnostic errors" while the shift in payment methodologies mean "accurate, timely diagnosis can be rewarded." The authors call for development of "validated metrics" that define how often certain errors occur, quantify their ramifications and identify factors that can reduce those errors.

Takeaway: IOM Report emphasizes need for teamwork and collaboration in the diagnostic process and communication about errors and near misses.