Patient Safety Begins at Diagnosis

BPHC's Jim Macrae addressing staff at HRSA's 7th annual Patient Safety Week observance
HRSA Bureau of Primary Health Care Associate Administrator Jim Macrae addressed spoke at HRSA's 7th annual Patient Safety Week observance, saying "we take (this) very seriously." HRSA supports 1,400 health centers serving over 27 million patients -- including quality assurance measures, technical assistance, trend-spotting and malpractice indemnity. A Harvard safety expert said more such practices are needed in health care.

"Far and away, the leading medical ... error is misdiagnosis. From the patients' perspective, this is the leading problem." -Dr. Gordon Schiff

Dr. Gordon Schiff of the Harvard University School of Medicine
Fixing what's broken: Schiff of the Harvard University School of Medicine is a leading expert in diagnostics and malpractice prevention.  He said doctors and patients need a more "open relationship" in which physicians acknowledge their own limitations and enlist their patients' help; a "less punitive" system of routine clinician review; and far more consultation between health professionals to catch errors. Schiff would know. He underwent unnecessary surgery in college due to a misdiagnosis, and has the scar to remind him of the consequences of clinician error.

One in twenty primary care patients have a health problem misdiagnosed every year -- and 41 percent say in surveys that their clinicians have gotten it wrong at least once -- a Harvard University expert reported last week in an address during Patient Safety Awareness Week.

This, said Dr. Gordon Schiff, "means to me from a safety point of view … there's preventable things happening (that) are harder and harder to defend."

He noted that one in five general medical malpractice lawsuits are settled, but twice as many cases of alleged misdiagnosis lead to out-of-court payments. One independent review of internists' case files, for example, found that they misdiagnosed an estimated 13 percent of patients with common conditions.

Schiff is among the co-authors of a foundational 2015 study for the National Academy of Medicine that implicated clinician error in perhaps "thousands of hospitalized patients" dying every year, sounding a clarion call for an overhaul of patient safety systems in institutions, large and small, including primary care.

Analyzing medical death rate data over an eight-year period, Johns Hopkins patient safety experts in 2016 calculated that more than 250,000 deaths per year HRSA Exit Disclaimer are due to medical error in the U.S. -- ranking it just behind heart disease and cancer as the third leading cause of mortality in the U.S.

Provider mistakes are made across medical specialties and health care systems around the globe, authorities agree.

"Errors are frequent, they are ubiquitous, and there is uncertainty inherent in diagnosis," Schiff said.

Reducing the prevalence requires a will to reform and adopt new approaches, starting with better teamwork -- or interdisciplinary care, a hallmark of HRSA-supported health center practice, observed Jim Macrae, Associate Administrator of the Bureau of Primary Health Care.

Clinicians should rely more on "objective" evidence; less on "unreliable" professional impressions and subjective information in arriving at diagnoses; do more cross-checking and consulting with their colleagues, and institute routine case reviews –- while spending more time talking to patients and less time on their computer tablets, Schiff posited.

Importantly, providers must be able to "grapple with uncertainty" at times -- when a diagnosis is unclear or they sense that they are at the edge of their personal knowledge. This means "being patient with tests and time (and recognizing) it's going to take a few weeks for us to see what's going on," said Schiff, whose published appraisals of clinical disasters have been credited with compelling a frank reassessment even of organizational psychology.

Clinicians would do well, for example, to listen closely to what a patient's caregivers have to say about their loved one's health and safety, particularly in the age of opioid misuse. Consider that a patient may insist that his or her health is fine –- but the family often knows better.

"This is often dismissed or not even sought after," Schiff said. "It's not a matter of science.  It's a matter of trying to gather as much data in a respectful way as possible."

Date Last Reviewed:  March 2019