This past week, The National Academies of Sciences, Engineering, and Medicine (NASEM) Institute of Medicine (IOM) released their latest report, Improving Diagnosis in Health Care. This report is a follow-up to the other sentinel reports by IOM that began in 1999 and raised the global consciousness on Patient Safety. In this latest report, the IOM points out in a way that has never been done before that issues related to medical error often involve missed or delayed diagnosis that can result in patient harm and delayed treatment. Allegations of medical negligence often include issues of missed or delayed diagnosis, but the circumstances are sometimes so varied that getting to any specific causal elements as to why the missed diagnosis happened can be difficult.
The report provides 8 goals that if reached can have a great impact on the reduction of diagnostic error and patient harm. Among other things, the report points out that the healthcare team must engage in the process of getting the correct diagnosis, and brings up key areas such as radiology and pathology that need to be part of that team. These services do more than run tests; they have highly skilled professionals who are used to looking at their individual test results as part of the overall picture of the patient. Potential pathology and their individual interpretations can be very helpful to creating a full clinical impression for the treating physician. Creating this type of collaborative care management can support enhanced diagnostic accuracy, treatment selection and patient satisfaction.
Creating a reporting culture for potential, near-miss and actual situations that includes diagnostic errors is another major goal of the IOM report. But it does not stop with reporting. Analyzing and learning from the data that are collected through reporting must occur in a safe place or "learning laboratory," where analytics can truly drive crucial process changes. There are many data collection systems available, and some are better than others. The challenges come in creating the appropriate data points that can inform the diagnostic process, and, more importantly, fostering the reporting culture among healthcare providers and empowering them to actually report these situations. Once this is done, the use of Patient Safety Organizations can lend broad analytical capabilities within the context of the protected learning laboratory, as outlined by the Patient Safety and Quality Improvement Act, which then has the opportunity to create greater clarity around causal elements that can help improve diagnostic accuracy.
The report was developed by the IOM and petitioned by the Society to Improve Diagnosis in Medicine (SIDM), which supports a collaborative approach to reducing preventable errors and delays in diagnosis across the healthcare continuum. We at Clarity are proud to be an early supporter of the Society to Improve Diagnosis in Medicine (SIDM) and their Diagnostic Error Awareness Campaign. SIDM is committed to raising awareness regarding diagnostic errors in healthcare and ultimately bringing about change. To accomplish its goal, the group participated in the launch of the Coalition to Improve Diagnosis and the development of this report. The report is a major milestone in the industry as it brings awareness of and action to diagnostic error, which they have found to be the leading type of medical malpractice claim, with 6-17% of all hospital adverse events being related to diagnostic errors. The report provides significant research into this area and outlines recommendations to improve diagnoses and make them more accurate, reliable, efficient, and safe. Visit the National Academy of Sciences to download the report.