Sat Aug 06 2022

Misdiagnosis can happen to you and your loved ones

baby holding an adults hand

In many nations, primary care services are becoming more and more vital to integrated, patient-centred healthcare. Although health care providers strive to deliver high-quality and safe care, accidents do happen occasionally. A lot of work has been done to study the origins, effects, and potential remedies of unsafe health care, which has been identified as a global crisis.However, because most of this research has thus far concentrated on hospital care, there is much less knowledge about how to enhance safety in primary care. Given that primary care today provides the majority of healthcare, it is crucial to comprehend the scope and nature of harm that occurs there. Millions of individuals use primary care services every day all across the world. Therefore, there is a great deal of potential for and need for damage reduction. Inadequate basic care can result in preventable sickness and injury, unnecessary hospitalizations, and in rare circumstances, disability and even death. On the other hand, good primary care may result in fewer avoidable hospitalizations.

baby holding an adults hand

Approximately 5% of adults experience diagnostic errors in outpatient settings annually, according to a research done in a high-income nation conducted by WHO. The potential for significant injury existed in more than half of these mistakes. The study's findings suggested that this figure was probably an underestimate and that diagnostic mistake rates in low-income nations would be significantly higher. It is unknown how common diagnostic mistakes are in children's cases. However, a study of paediatricians in a wealthy nation revealed that more than half admitted to diagnostic mistakes at least twice a month and acknowledged dangerous mistakes at least once or twice a year. Due to limited access to diagnostic testing tools, a shortage of experienced primary care providers or specialists, and constrained record-keeping systems, difficulties may be even more severe in low and middle-income nations. These elements could lead to a higher incidence of diagnostic mistakes in primary care.

Underlying causes of diagnostic errors

baby holding an adults hand

Error is possible at every step of the diagnostic procedure. Studies on diagnostic error frequently show that every case has a variety of underlying causes. Cognitive errors, such as incorrectly summing up the available evidence or failing to use physical examination or test data appropriately, can be one of the causes. In fact, there is proof that in more than half of diagnostic error situations, cognitive errors can be found. Diagnostic mistakes may also be caused by system defects due to issues with coordination of care, communication, access to specialists, and availability of medical record data. According to a study conducted in one developed nation, A total of 68 distinct diagnoses were missed in 190 patients. Acute renal failure (5.3 %), pneumonia (6.7 %), decompensated congestive heart failure (5.7 %), primary cancer (5.3 %), and urinary tract infection or pyelonephritis (4.8 %) were the most frequently missed diagnoses in primary care. The clinical encounter between a patient and a practitioner was the process breakdown that occurred the most frequently (78.9%), but it was also related to referrals (19.5%), patient-related factors (16.3%), follow-up and tracking of diagnostic information (14.7%), and the execution and interpretation of diagnostic tests (13.7 % ). A total of 43.7% of cases involved more than one of these processes. Problems with taking the patient's history (56.3%), performing the examination (47.4%), and/or requesting diagnostic tests for additional workup were the main causes of patient-physician contact breakdowns (57.4 % ). Most errors have the potential to cause moderate to severe injury.

FactorsPossible issues contributing to error
Access to high quality primary careLimited access due to lack of money, remoteness, illiteracy, travel constraints or a limited number of health care facilities.
Availability of health care professionals and specialistsLack of sufficient, competent health care professionals, for example, due to lack of training, outward migration or a poor employment situation. Specialty expertise may not exist or may be limited in number or quality.
TeamworkPoor teamwork, lack of learning and feedback when errors occur.
Availability of diagnostic testsDiagnostic tests limited in scope, availability or quality.
CommunicationLittle or no sharing of medical information.
Care coordinationConsultations delayed or test results lost or a lack of health records documenting care.
Follow-upLimited follow-up reduces the ability for diagnostic impressions to evolve.
Affordability of careCare unaffordable or compromises other basic needs such as food or housing.
Training of health care providersTraining is suboptimal, in particular lack of training for clinical reasoning; certification and licensure requirements are deficient.
Availability of health informatics resourcesHealth informatics resources, including internet access, may not be available, especially in remote areas; unaffordable subscription or download fees for medical information.
CultureSome cultures may be punitive, which discourage sharing and inhibit learning; physician-centric systems limit the value of the team. Patients may feel it is more appropriate to be passive care recipients.
Human factors and cognitive issuesThe work environment and systems may be subject to distractions, interruptions and a lack of organization of information.

Moving Forward

Primary care must be safe and of good quality in order to maintain and improve health and reduce reliance on hospital care. Although diagnostic errors are common and damaging in primary care, unfortunately much is still unclear about them. Addressing errors, especially diagnostic errors, is a key component of enhancing primary care safety. Patient safety concern affects every country and diagnosis, and many stakeholders are involved. There is no one intervention that can be used to prevent diagnostic errors, and interventions must be thoroughly reviewed for benefits and unexpected consequences. Among the strategies that healthcare systems could prioritise are:

  1. Supporting the workforce
    Students watching doctors performing surgery
    • Ensuring that the primary care workforce receives education on patient safety. Education about delayed and missed diagnoses should become part of mandatory training and continuing professional development
    • Including education about cognitive psychology and systems thinking routinely in curricula so that health care providers understand root causes and the importance of system level approaches
  2. Including patients as part of the care team
    Students watching doctors performing surgery
    • Encouraging patients to be proactive about asking for information and followup. Providers need to be trained to partner with patients and encourage these questions, so patients become a true partner in the diagnostic process.
  3. Using supportive tools
    Students watching doctors performing surgery
    • Building error-reporting systems to encourage learning from errors
    • Using health technologies, such as remote consultations, so that health care providers can get rapid access to specialists and senior colleagues
  4. Improving diagnostic facilities
    Students watching doctors performing surgery
    • Improving access to diagnostic tests in primary care, including point-of-care testing
    • Improving system design by accounting for human factors.
  5. Prioritizing areas for improvement
    Students watching doctors performing surgery
    • Targeting conditions with high rates of diagnostic errors for improvement interventions, such as cancer, cardiovascular conditions and infections;
    • Investing in research into causes and solutions for diagnostic errors so that interventions can be adapted to the local context.
  • Diagnostic Errors, Technical Series on Safer Primary Care,
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