Culture Change is Key to Reducing Diagnostic Errors

Can lean strategies help doctors make fewer diagnostic errors?

Most healthcare process improvement efforts focus on preventing treatment errors – making sure patients are given the correct course of treatment after a diagnosis has been made. But diagnostic errors also occur, an issue I wrote about nearly a year and a half ago.

I’m revisiting that issue now because a new survey has shed some light on diagnostic errors. A group of researchers led by Gordon Schiff, MD, associate director at the Center for Patient Safety Research and Practice at Brigham and Women's Hospital in Boston, asked doctors to describe – anonymously – diagnostic errors they had made or witnessed.

Their findings, published in the Archives of Internal Medicine, are based on the responses from the doctors, who reported 583 errors. An article in Physician Leadership News described the findings.

The two most frequently listed conditions involved pulmonary embolism and adverse drug reactions, including overdoses and poisoning. Lung cancer diagnostic mistakes ranked a close third, followed by colorectal cancer, acute coronary syndrome, breast cancer, and stroke.

The doctors failed to: order tests, report the results to their patients or follow-up when testing revealed abnormal findings.

As it turns out, lab and radiology testing errors, including test ordering, test performance, and clinician processing, accounted for 44% of the missed diagnoses, which was the greatest share.

Most lean advocates would probably suspect that system problems contributed to the errors, as much or more so than physician error. The article, by Heather Comak and Cheryl Clark, discusses that issue.

While the notion of overconfident, arrogant physicians being the cause of diagnosis error is not wholly wrong, those qualities alone are certainly not the reason that misdiagnoses are made, said Schiff. Other factors include spotty follow-up, time pressure, failure of physicians to share their uncertainties, malpractice fears, defensiveness, and inadequate feedback.

Schiff likened this last factor to the lawn sprinkler system that goes on automatically, regardless of whether it has rained that day. Instead of acting in a closed-loop system that provides feedback about whether diagnoses were right or wrong, often physicians work in an environment that does not allow for this follow-up or does not attempt to capture this feedback.

The article goes on to note that cultural biases and culture change – the most difficult aspect of any improvement effort – are at the heart of the situation.

Another way of thinking that has become ingrained in most physicians is the idea that an overconfident, perhaps wrong diagnosis is better than not diagnosing a patient at all. Most patients don't appreciate when their physicians don't seem decisive about a diagnosis, and historically, physicians have been more successful when they confidently make a diagnosis, said Croskerry. Additionally, physicians validate their ability to make diagnoses when they are confident.

"Physicians tend to place a lot of faith in their own diagnoses—most physicians think it's the most important skill that they have," said Croskerry. "It's a lot easier, if you give the patient wrong medication, to admit to something like that than to actually admit to your thinking processes having gone astray. People take that far more personally..."

Both Schiff and Croskerry agreed that more emphasis should be placed on physicians admitting to their patients uncertainty about diagnosis and that more work needs to be done at an earlier stage, perhaps in medical school, to introduce the idea of feeling comfortable with uncertainty to physicians. Additionally, Schiff said the question of physicians admitting a diagnosis error is first and foremost about a patient safety culture.

"This idea about patient safety culture—creating a system where people can honestly look at errors in a blame-free way, learning from mistakes and improving from those, rather than covering them up or having to defend them—is so central for us learning," said Schiff.

It is going to take a long time and a lot of work to achieve this kind of culture change. I hope this new survey will contribute to that effort.