Janelle M. Chiasera, PhD, ASCLS Region III Director
Fifteen years after the release of the Institute of Medicine’s (IOM) landmark report, To Err Is Human: Building a Safer Health System, a follow-up report released by the IOM in 2015 makes the case that the delivery of health care continues to proceed with a glaring blind spot, diagnostic errors. If you recall from their report in 2000, the IOM not only revealed the common fact that all humans make mistakes, but they brought to light another important obvious fact, that those of us in health care, as human beings, are also prone to make mistakes. After the release of the report in 2000, a new trend began in healthcare organizations, one focused on addressing the safety and quality of healthcare. Dial forward fifteen years and this could and should result in a paradigm shift in our role as medical laboratory scientists and, more importantly, the role we will play in defining, communicating, and providing evidence for the impact of the contribution we will make to healthcare moving forward.
The 2015 IOM report focuses on three important major topics. First, this report uncovers a critical type of error in healthcare – diagnostic error – that has received little to no attention since the To Err is Human report. The report outlines some reasons as to why this may be the case including sparse data, few reliable measures, and the fact most errors are identified in retrospect. Regardless, the IOM believes the most important contribution they can make in this report is to highlight the importance of the issue and to direct discussion among patients, healthcare professionals, and healthcare administrators. Second, the IOM believes patients and their families are central to the solution and, as such, they recommend healthcare organizations develop partnerships with patients and families to help improve diagnosis. Third, the IOM emphasizes the diagnostic process, human health, and human disease are very complex and, because of this complexity, require intra- and inter-professional teamwork and collaboration for the efficient and effective delivery of healthcare currently and in the future.
The report identifies five issues that will reduce diagnostic errors:
- Healthcare professional education and training does not take fully into account advances in the learning sciences. The report emphasizes training in clinical reasoning, teamwork, and communication.
- Health information technology, while potentially a boon to quality healthcare, is often a barrier to effective clinical care in its current form. The report makes several recommendations to improve the utility of health information technology in the diagnostic process specifically and the clinical process more generally.
- There is little data on diagnostic error. The report recommends, in addition to specified research, the development of approaches to monitor the diagnostic process and to identify, learn from, and reduce diagnostic error.
- The healthcare work system and culture do not sufficiently support the diagnostic process. Echoing previous IOM work, the report also recommends the development of an organizational culture that values open discussion and feedback on diagnostic performance.
- In addition, the report highlights the increasingly important role of radiologists and pathologists as integral members of the diagnostic team.
Finally, the report provided eight goals to improve diagnosis and reduce diagnostic error
Goal 1: Facilitate more effective teamwork in the diagnostic process among healthcare professionals, patients, and their families
Goal 2: Enhance healthcare professional education and training in the diagnostic process
Goal 3: Ensure that health information technologies (IT) support patients and healthcare professionals in the diagnostic process
Goal 4: Develop and deploy approaches to identify, learn from, and reduce diagnostic errors and near misses in clinical practice
Goal 5: Establish a work system and culture that supports the diagnostic process and improvements in diagnostic performance
Goal 6: Develop a reporting environment and medical liability system that facilitates improved diagnosis by learning from diagnostic errors and near misses
Goal 7: Design a payment and care delivery environment that supports the diagnostic process
Goal 8: Provide dedicated funding for research on the diagnostic process and diagnostic errors
Given the importance of the diagnostic process to patients and to health care decision-making, as well as the pervasiveness of diagnostic errors in practice, it is surprising this issue of diagnostic errors has been neglected within the quality improvement and patient safety movement of the past decade. Regardless, this is our time. This is our time because the environment around us is changing and those around us are calling us to action. We can respond in two ways, we can remain inside the laboratory and continue to do things as we always have, or we can answer this call to action together by defining the contribution we will make. I leave you with one of my favorite quotes and challenge you to take a role in answering this call.
“If you always do what you’ve always done, you’ll always get what you’ve always got.”