How to Prevent Medical Diagnostic Errors

Address Errors Created in Systems

Many systems errors are those involving delays in patients seeing a specialist or getting a diagnostic test, as well as delays in getting test results back to the initial physician. And, beyond a slowly moving system of communication, there are errors in the communication itself.

Physicians may rely on their own reading of a scan or the written notes that accompany it rather than talk to the radiologist, said Dr. Graber. Subtleties or secondary, nonobvious findings might be missed. These things are easily communicated in a live conversation, but it can be next to impossible to get two physicians on the phone at the same time. “Why doesn’t this happen? Because communication is burdensome,” Dr. Shah said. “The radiologist’s call interrupts my work flow. I call him back and interrupt his work flow.”

Better notes could help, but it’s complicated by the variety of systems. “Even notes are tricky, because different facilities use different EMR platforms and they’re not compatible,” Dr. Shah said.

Checklists, which are are becoming more popular with surgeons, are sometimes very group specific, built for a particular specialty at a particular hospital. But so far these tend to be more procedural than diagnostic. Usually you start with the diagnosis and then the decision tree follows, Dr. Folbe said.

Computerized diagnostic algorithms may be a physician’s tool of the future, but for now simply recognizing one’s limits would help. “We’re not supercomputers,” Dr. Folbe said. “It’s okay to look things up. It’s okay for physicians to admit they don’t know something or to consult with their colleagues.”

The focus on systems is worthy, but a true human factors analysis is a big investment of time and resources. “For a small otolaryngology practice, there’s no budget for this,” Dr. Shah said.

He offered up a low-cost solution: the pneumonic STAR, which stands for stop, think, act, review. “It’s very simple but it can be very helpful,” Dr. Shah said. “For me, it’s a reminder to stop and focus on what’s in front of me,” he adds, whether it’s a patient or a scan or a prescription. Even if—or especially if—your pager is buzzing.

Jill Adams is a freelance writer based in New York.