AHRQ Views

Blog posts from Richard Kronick, Ph.D., and other AHRQ leaders

SEP

2015

New Coalition Broadens Efforts to Reduce Diagnostic Errors

By Richard Kronick Ph.D.

As patients, we assume that a medical diagnosis is the first step in getting the right treatment for an illness or injury. However, a diagnosis that’s delayed or incorrect can set off a series of negative events, resulting in unnecessary and costly tests and procedures, potentially worsened health outcomes, and even death.

The National Academy of Medicine’s new report, Improving Diagnosis in Health Care

, reveals that most people will experience at least one diagnostic error in their lifetime, whether it’s an incorrect diagnosis of a heart condition or a cancer diagnosis that’s delayed. These problems occur in all settings of care and harm an unacceptable number of patients. While data are sparse, these errors contribute to approximately 10 percent of patient deaths and between 6 percent and 17 percent of hospital adverse events, according to the report.

AHRQ and a wide range of groups are focused on finding solutions to the problems outlined in the report. The newly formed Coalition to Improve Diagnosis

, of which AHRQ and the Centers for Disease Control and Prevention are government partners, is bringing together researchers, physicians, nurses, patients, and other stakeholders to discuss the problem of diagnostic error and potential strategies to reduce its impact. The coalition, which was formed by the Society to Improve Diagnosis in Medicine (SIDM), includes the following members:

ABIM Foundation
American Association of Nurse Practitioners
American Board of Internal Medicine
American Board of Medical Specialties
American College of Emergency Physicians
American College of Physicians
American Society for Healthcare Risk Management
Consumers Advancing Patient Safety
The Leapfrog Group
National Patient Safety Foundation

On September 28, I will deliver a keynote address at SIDM’s Eighth Annual Diagnostic Error in Medicine International Conference

in Alexandria, VA. My remarks will focus on solutions, including approaches to measuring the extent of the problem of diagnostic errors and the development of standardized methods for reporting.

In addition, I will note that effective feedback is a crucial driver for improvement but that several barriers impede critical feedback about the diagnostic process. Wider adoption of tools such as AHRQ’s team training program,TeamSTEPPSR, could help facilitate candid, efficient, and constructive feedback about performance. Better communication, which is a fundamental part of teamwork, could help busy health care providers overcome barriers and restore professional interactions. Such changes could help our health care system function as a true “learning system” that ultimately serves patients better.

In addition, I will discuss the significant role that Patient Safety Organizations can play in this effort by providing safe and confidential environments to support learning from diagnostic error. AHRQ will continue to engage with PSOs and consider how their capabilities and the services they offer to providers in conjunction with the protections provided through the Patient Safety and Quality Improvement Act can most effectively contribute to improving diagnosis and other safety and quality challenges.

As an early sponsor of research examining the issue of diagnostic error to make care safer for patients, AHRQ is gratified to see this complex and important problem getting the attention that it deserves. Learning how to identify and reduce the incidence of missed, incorrect, and delayed diagnoses—and putting those lessons into everyday medical practice—will go a long way toward helping us build a better and safer health care system.

Page last reviewed September 2015

Internet Citation: New Coalition Broadens Efforts to Reduce Diagnostic Errors. September 2015. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/blog/ahrqviews/092415.html