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5 Ways to Reduce Costly Diagnostic Errors

 |  By Sandra Gittlen  
   June 05, 2017

Healthcare providers are working to improve diagnostic accuracy. Here are five tips from four experts.

This is an excerpt of an article that first appeared in the October 2016 issue of HealthLeaders magazine.

Diagnostic errors, no matter their origin, are costly.

The National Academies of Sciences, Engineering, and Medicine—Health and Medicine Division found that 5% of U.S. adults who seek outpatient care each year experience a diagnostic error.

Diagnosis-related payments, Johns Hopkins researchers found, amounted to $38.8 billion between 1986 and 2010.

But there are things physicians and care teams can do to improve diagnostic accuracy.

1. Expand Your View

Through his work in ambulatory care clinics, Mikael Jones, PharmD, BCPS, clinical associate professor at the University of Kentucky College of Pharmacy, says he has realized that an efficient way to decrease diagnostic error rates is to form cohesive care teams.

He points to the case of an elderly patient he consulted on five years ago. The woman presented to the clinic with severe diarrhea and generally wasn't feeling well. Her history showed a recent course of antibiotics, and the nurse practitioner was worried about Clostridium difficile colitis or C. diff, which would be catastrophic in a patient her age.

Before concluding that diagnosis, Jones asked about other medications she was taking. The woman had been consuming a dietary herbal supplement, which Jones found to have a high likelihood of causing diarrhea.

"I suggested taking a step back and seeing if stopping the supplement would make a difference, and it did," he says. Ultimately, the woman did not have to undergo taxing C. diff treatment.

Jones learned from that experience to make the diagnostic process a team sport and to be more specific in patient questioning. "Don't just ask about medications; ask them about prescription, non-prescription, and supplements," he says.

2. Follow the Data

Information flow has to improve, too, he says. For instance, while e-prescribing has made it easier to get prescriptions to pharmacies, the information flow back to the prescriber about whether a patient has filled the prescription is lacking.

Knowing how soon the prescription was picked up also is important because some medications, to be effective, have to be taken in a certain time frame.

He also believes provider notes should be looked at as a way to reduce diagnostic errors. "The notes are getting longer and longer and a lot of information is being imported. One incorrect fact can be easily propagated," he says.

"I make sure to look at all medication notes and reconcile them with what the patient is saying and what was intended by the healthcare provider."

3. Insist on Report Clarity

Poor documentation can also flummox radiologists, according to Joseph Glaser, MD, at Middletown, New York-based Radiologic Associates, PC. He says more attention has to be paid to basics such as systematic reporting.

"In communicating results, you not only have to report what's urgent and important, but also secondary findings," says Glaser, a nuclear medicine physician.

For instance, if a patient comes in for a chest x-ray with a presumed diagnosis of pneumonia, the report must not only describe whether there are clear lungs, but also the observation of a broken rib. "We may find a surprise that can change patient management," he says.

And how these findings are relayed to the doctor is equally important. While new technology has helped tremendously, he says, there are still times when a simple phone call is the most effective way to ensure timely and clear communication. This can also help on the incoming end as well.

He encourages imaging physicians to learn how referring doctors receive information and incorporate those preferences into their reporting. "Doctors on both ends can suffer from information overload, so it's better to know what findings they want about certain conditions," he says.

4. Go Slowly and Stay Steady

Don Goldmann, MD, chief medical and scientific officer at the Institute for Healthcare Improvement, agrees that clinicians are moving too fast these days, leaving the opportunity for diagnostic errors.

"Physicians used to take the time for careful observation, but now we think everything has to be solved right away," he says, adding "not all diagnoses are evident right away."

This hurry extends to direct patient interaction. "Physicians don't tend to wait for patients to answer questions. If there's any pause, they fill it with the next question or their opinion," he says.

By slowing down, he says, physicians can gain tremendous insight on issues such as family problems that are causing stress. Knowing this might avoid needless tests looking for very unlikely chronic conditions.

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"The worst thing to do is to order a bunch of tests to cover yourself because you're worried you'll miss something. Every test has a margin of error, so they will likely lead to more tests," he says, which, in turn, "will do more harm than good."

He says physicians who do order tests must get better about closing the loop on delivering results to patients. "Misdiagnoses can be made simply because the referral loop isn't closed and assumptions are made about who knows what," he says.

5. Close the Loop

Closing the loop is a mission for Johns Hopkins Community Physicians, a network that includes internal medicine, family practice and pediatrics, and specialty services with locations in Virginia, Maryland, and the District of Columbia.

Johns Hopkins Community Physicians has created redundant processes in the EMR system to ensure that physicians are alerted in a reasonable time when tests they've ordered have been completed, says President Steven Kravet, MD, MBA, FACP. The system also alerts physicians when they haven't been received in a reasonable amount of time so they can be checked on.

"I don't believe no news is good news," Kravet says. The goal is to avoid results falling off the map like an abnormal Pap smear that gets sent to the wrong doctor and the patient is never called.

The network now labels certain tests "critical" so physicians can run reports and quickly track down missing results. Even noncritical tests are reported on so that all results make their way into the system.



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