The frontiers of medicine are constantly advancing, new treatments continue to emerge, and previously incurable conditions can be readily treated and cured. But essential and life-saving treatments can be denied because the diagnosis of illness is either delayed, missed or entirely wrong. These errors may overlap in any given patient. My own speciality of emergency medicine is a particularly high-risk area as far as diagnostic error is concerned.
Diagnostic errors can be costly. The victim may be harmed physically, which includes, in extreme cases, the loss of life or permanent disability, and may be damaged psychologically. The NHS may end up paying for the additional costs of prolonged treatment needed to set things right. When victims go on to sue, the costs of litigation add to the total. In 2018/19, NHS Resolution paid out £2.4 billion for clinical negligence claims, most of which were the direct result of diagnostic error. The corresponding figures for 2017/18 were £2.2 billion and for 2016/17 £1.7 billion.
The doctor (s) responsible for serious diagnostic errors may also suffer emotional distress, sometimes even being described as the “second victim (s)”. A fear of making mistakes, especially in litigious societies, leads to costly defensive medicine, leading to cautionary and unnecessary investigation and treatment.
Some pioneering reports have led to a wider discussion of diagnostic error. The Institute of Medicine of the US National Academy of Sciences launched its Quality of Health Care in America project in June 1998. The first report, To Err is Human, appeared in November 1999, and was followed by the Crossing the Quality Chasm: A New Health System for the 21st Century, in 2001, and Improving Diagnosis in Health Care, in 2015. The Chief Medical Officer of England was responsible for the 2000 report entitled An organisation with a memory: Report of an expert group on learning from adverse events in the NHS. There is an increasing body of literature, including articles and books, that are concerned with diagnostic errors in medical practice.
Diagnostic errors are, however, still under-reported. There is little incentive to report mistakes, especially when doctors may fear reprisals which may adversely affect their professional careers. A “name, blame and shame” culture is unfortunately common, despite a desire to move towards either a “no blame” or more realistically a “just blame” culture. This can help shift the focus away from the individual to the system within which they work, which is more helpful in preventing repetitions of the same mistakes. It is unsurprising that there is a widespread public perception of a wall of silence in healthcare when it comes to admitting that mistakes have taken place.
The NHS collects massive amounts of data about patients, but this “big data” has not been harnessed to benefit quality of patient care in a meaningful way. This has led to a lack of objective knowledge about how and why mistakes in diagnosis arise. Learning opportunities continue to be missed as information sharing within the NHS is not as good as it should be.
There are some ways in which diagnostic errors can be recognised following care that has been provided in the emergency department:
- Self-reporting, in real time, in a informational database is probably the best option where available. This process can be anonymized to ensure compliance and encourage wider usage.
- Unplanned return to the emergency department because of unresolved or new symptoms that are related to the initial presentation. This measure can be regarded as a surrogate measure of the quality of care.
- Serious incident reporting in the hospital
- Complaints made by patients, their friends or relatives
- Legal claims lodged by the victims of clinical negligence
- Retrospective reviews of patient records, with a view to actively seeking out mistakes
- Post-mortem examinations to determine the cause for unexplained death.
Unfortunately, we have a long way to go. Better IT support is essential to making the NHS a safer place to be treated in.
Ashis Banerjee (ex-NHS)