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Reflections on Safety is a monthly column presenting the insights of Tejal K. Gandhi, MD, MPH, CPPS, Chief Clinical and Safety Officer, Institute for Healthcare Improvement (IHI). Dr. Gandhi was president and CEO of the National Patient Safety Foundation prior to its merger with IHI in May 2017.


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Diagnostic Error in the Spotlight

Posted By Administration, Friday, September 11, 2015

As we anticipate the upcoming Institute of Medicine report on improving diagnosis, NPSF joins with other organizations to think about the next steps. 

By Tejal K. Gandhi, MD, MPH, CPPS

  Tejal K. Gandhi    


Later this month, I will be among the speakers at the Diagnostic Error in Medicine 8th International Conference, hosted by the Society to Improve Diagnosis in Medicine (SIDM). The theme of this year’s meeting — After the IOM Report: What's Next? — gets to the heart of what many of us have been anticipating: release of an Institute of Medicine report on improving diagnosis.


While we don’t yet know the report’s findings, early news reports indicate that it will build upon existing research and knowledge about diagnostic error:

  • There are multiple causes and reasons for missed, delayed or wrong diagnosis, from communication breakdowns and inadequate use of information technology to cognitive errors by physicians, such as confirmation bias. In fact, in a study published in 2006, my co-investigators and I found that most cases of diagnostic error involve both systems-related factors and cognitive errors.

  • More research is needed into how diagnostic errors occur and how we can help prevent them. A 2012 paper suggested interventions such as greater patient engagement, better use of information technology, and focused interventions to avoid specific, known pitfalls.

  • Missed, delayed, or wrong diagnoses are a neglected area of patient safety, and no one is really measuring the problem. The approaches we normally use to identify adverse events won’t work for diagnostic errors. Even the Global Trigger Tool, created by the Institute for Healthcare Improvement and widely thought to be the best tool available to identify adverse events in hospitalized patients, captures few cases of diagnostic error, because it is designed to assess treatment flaws.

While most patient safety efforts have been made in the inpatient setting to reduce treatment errors, far more care is delivered in outpatient settings, and studies of malpractice cases show that diagnostic error is the chief claim in ambulatory care. By some estimates, 1 in 20 adults in the US have been or will be affected by diagnostic error.


The good news is that the IOM report is sure to bring much needed attention to this area of vulnerability for patients. NPSF recently joined the Coalition to Improve Diagnosis, which is led by SIDM and comprises a number of organizations committed to bringing awareness, attention, and action to the problem of diagnostic error.


As we await the IOM report, I encourage you to read Myths and Facts About Diagnostic Error, which NPSF and SIDM prepared jointly for Patient Safety Awareness Week 2014.


Have you experienced missed, delayed, or wrong diagnosis, either as a clinician or a patient? Comment on this post below. Note: To comment, you must first register on the website. If you are already registered, you must log in to comment.


Tejal K. Gandhi, MD, MPH, CPPS, is president and chief executive officer of the National Patient Safety Foundation and of the NPSF Lucian Leape Institute.

Tags:  diagnosis  diagnostic error  IOM 

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