IOM Report Calls for Collaborative Effort To Reduce Diagnostic Errors

Too little attention has been paid to diagnostic errors, an issue that could become worse if it is not addressed, according to an Institute of Medicine report released this week, Hospitals & Health Networks reports (Stempniak, Hospitals & Health Networks, 9/22).

According to the report, most people will experience one or more diagnostic errors, which are delayed or inaccurate diagnoses, in their lifetimes (IOM report, September 2015). Further, the report notes that diagnostic errors contribute to about 10% of all patient deaths (Hospitals & Health Networks, 9/22). The errors also account for up to 17% of hospital adverse events.

The report calls diagnostic errors a "blind spot" for health care systems, adding that few providers have processes to spot diagnostic mistakes or near misses, while many organizations have cultures that discourage learning from such mistakes (IOM report, September 2015).

Recommendations

John Ball, chair of the IOM committee that authored the report, in a release said that because diagnosis "is a collective effort" that often involves a care team, making the necessary changes to reduce errors requires looking "more broadly at improving the entire process of how a diagnosis is made" (IOM release, 9/22).

To address the issues, the IOM report called for:

• Promoting more effective collaboration in the diagnostic process among clinicians, patients and their families (Hospitals & Health Networks, 9/22);
• Improving training for health care professionals so it emphasizes communication, clinical reasoning, teamwork and diagnostic testing (IOM report, September 2015);
• Placing more emphasis on learning from diagnosis errors and close calls in clinical practice;
• Designing a payment and care delivery environment that helps to support the diagnostic process;
• Allocating dedicated funds to research diagnostic errors and, more broadly, the diagnostic process; and
• Reforming the medical liability system and encouraging voluntary reporting efforts to help foster a culture of transparency and disclosure (Hospitals & Health Networks, 9/22).

Comments

IOM President Victor Dzau called the report "a serious wake up call," adding that "diagnostic errors are a significant contributor to patient harm that has received far too little attention until now." Dzau said he is "confident" the report "will have a profound effect not only on the way our health care system operates but also on the lives of patients" (IOM release, 9/22).

Meanwhile, Paul Epner, executive vice president of the Society to Improve Diagnosis in Medicine, said the report "addresses a significant gap in our knowledge, and SIDM intends to drive review and action on the recommendations across the entire health care system" (SIDM release, 9/22).