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Reducing diagnostic error

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It has been estimated that the diagnostic error rate in a general practice setting is 10–15%.¹ Fortunately, most of these errors do not cause harm to patients, but some do. Indeed, MDA National’s data indicates diagnostic error is the underlying cause of approximately half of the medical negligence claims involving Australian GPs.
 
What is diagnostic error?
The Institute of Medicine’s 2015 report, Improving diagnosis in health care, defines diagnostic error as the failure to:²
 

1. establish an accurate and timely explanation of the patient’s health problem(s) or
2. communicate that explanation to the patient.

 
Causes of diagnostic errors
Diagnostic errors often have multiple causes, with a median of three process breakdowns per error.³ As a result, there are a number of opportunities to prevent an error from occurring in the first place.
 
Most errors have their origins in both system failures and faulty cognition. In the past, much attention has been paid to system failures, such as the failure to inform a patient about a clinically significant test result due to the result or having being overlooked, or because the practice had incorrect patient contact details.
 
But what about cognitive errors? These may involve inadequate knowledge, poor data collection and organisation, faulty synthesis and biased thinking. For the individual GP, building knowledge (such as illness scripts) and knowledge organisation are important means of reducing diagnostic error.
 
Experienced doctors can spend up to 95% of their time making decisions using non-analytic processing (also known as ‘intuitive’ or ‘system 1’ reasoning).⁴ This provides highly efficient, rapid decision-making that allows GPs to cope with the complexity of clinical medicine with a high level of accuracy.
 
The speed of non-analytic processing relies in part on heuristics (mental shortcuts or ‘rules of thumb’) that allow a rapid response to information, eg a spot diagnosis of shingles. When this fails, it is often caused by cognitive biases.
 
The most common cognitive mistake in the diagnostic process is premature closure, where there is a tendency to stop the consultation and/or diagnostic process without an appropriate consideration of alternative diagnoses, and before the correct diagnosis has emerged.
 
However, some errors may appear to be related to biases when, in fact, they arise from limited knowledge. For example, a GP may be unaware of the triple test for the investigation of a breast lump, or not know that a disease may present in a certain manner and therefore not ask the necessary questions.
 
Techniques to reduce cognitive errors
Some of the ways in which cognitive errors can be avoided include:⁴
 

• building and strengthening the repository of illness scripts
  • knowledge of atypical presentation of diseases
  • symptom-based and case report reading

 

• ‘thinking about your thinking’
  • what else could this be?
  • what finding doesn’t fit with my diagnosis?
  • is there any reason I need to slow down?

 

• acknowledge emotions
  • external demands
  • internal stresses
  • emotions stemming from patient interactions

 

• reducing reliance on memory
  • use of checklists, clinical references
  • and/or clinical decision support tools.

 
The authors of Improving diagnosis in health care conclude:
Diagnostic errors persist throughout all settings of care and continue to harm an unacceptable number of patients.
 
Improving the diagnostic process is not only possible, but also represents a moral, professional, and public health imperative.
 
This article is provided by MDA National. They recommend that you contact your indemnity provider if you need specific advice in relation to your insurance policy.
 

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diagnosis diagnostic-error

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