Fatigue and stress are contributing factors to a doctor making a diagnostic error. — Filepic (unrelated to article)
World Patient Safety Day (WPSD) is commemorated on Sept 17 every year.
It is an opportunity for increasing public awareness and fostering collaboration between patients, healthcare professionals, policymakers and healthcare leaders to improve patient safety.
The theme for WPSD 2024 is “Improving diagnosis for patient safety” and the slogan is “Get it right, make it safe”.
This highlights the critical importance of correct and timely diagnosis in ensuring patient safety and improving health outcomes.
Errors in diagnosis
Every patient’s health problem requires a diagnosis, which is critical to the care and treatment needed for the condition.
Correct and timely diagnosis is dependent on factors that include knowledge, experience and skill of the healthcare professionals, and the resources available.
The diagnosis of a health problem often occurs over time, rather than at one point in time.
The diagnostic process involves taking the history of the problem; physical examination; initial clinical assessment; diagnostic tests, which need to be interpreted; follow-up and monitoring; referrals at times; communication and coordination; final diagnosis; and formulation of a treatment plan.
The success, or otherwise, of the treatment plan depends on patient behaviour, adherence and engagement.
Errors can occur at each of these stages.
Diagnosis is a high-risk area for errors, particularly in primary care where healthcare professionals typically have high patient volumes and whose patients have conditions that are often difficult to diagnose because of different presentations.
In addition, primary healthcare professionals may have limited experience with uncommon diseases and varying access to diagnostic tools.
Diagnostic errors occur when the diagnosis is missed, wrong or delayed.
For example, despite symptom(s), cancer is missed; patients are informed of one diagnosis when in fact it is actually something else; or the test result is suggestive of cancer, but the patient was not informed or was informed late.
Diagnostic errors account for 16% of preventable harm globally, and are common in clinics and hospitals.
Its consequences include worsening of patient conditions and outcomes, prolonged or severe illness, disability, or even death, and increased healthcare costs.
Malaysia’s data
There is a lack of data on diagnostic errors in Malaysia.
A paper published December 2012 in the journal BMC Family Practice (now known as BMC Primary Care) reviewed 1,753 medical records randomly selected from 12 Malaysian public primary care clinics for “diagnostic, management and documentation errors, potential errors causing serious harm and likelihood of preventability of such errors”.
The researchers found that: “Diagnostic errors were present in 3.6% of medical records and management errors in 53.2%.
“Medication errors were present in 41.1% of records, investigation errors in 21.7%, and decision-making errors in 14.5%.
“A total of 39.9% of these errors had the potential to cause serious harm.
“Problems of documentation, including illegible handwriting, were found in 98.0% of records.
“Nearly all errors (93.5%) detected were considered preventable.”
Another study, published January 2021 in the Malaysian Journal of Medicine and Health Sciences, looked at 180 cases attended to in the Emergency Department of a university hospital from May 2016 to December 2017, to determine if the admission diagnosis matched the discharge diagnosis.
It was found that 15.6% of the diagnoses did not match.
The odds of having unmatched diagnoses in patients from the green zone were 4.2 times higher compared to the red zone.
Meanwhile, a review, published August 2020 in the journal Frontiers in Immunology, aimed to determine the prevalence rates of primary immunodeficiency diseases (PID) cases, diagnosed from Jan 1, 1979, to March 1, 2020.
It concluded that “PIDs are underdiagnosed and under-reported in Malaysia.
“Developing PID healthcare and a national patient registry is much needed to enhance the outcome of PID patient care.”
What was disconcerting was a study involving 276 randomly-selected doctors in a tertiary public hospital from July to December 2015, published January 2017 in the journal BMC Medical Ethics.
It reported that only 28 (10.1%) intended to disclose medical errors.
The authors concluded that: “Most doctors in this study would not disclose medical errors, although they perceived that the errors were serious and felt responsible for it.”
Factors that cause errors
Diagnostic safety can be significantly improved by addressing the systems- based issues and cognitive factors that can lead to diagnostic errors.
Correct and timely diagnosis requires collaboration between patients, families, caregivers, healthcare professionals, healthcare leaders and policymakers.
All stakeholders have to be engaged in shaping the diagnostic process and be prepared to voice any concerns.
There are solutions to address diagnostic errors.
Healthcare leaders and policymakers, and healthcare professionals, have to recognise the systemic causes of diagnostic errors.
They are organisational vulnerabilities that predispose to diagnostic errors, and include:
- Communication failures between healthcare professionals and other healthcare professionals
- Communication failures between healthcare professionals and patients
- Heavy workloads
- Ineffective teamwork, and
- Healthcare professionals’ morale.
Policymakers and healthcare leaders should promote workplace environments that enhance diagnosis and provide the necessary quality diagnostic tools.
Whilst the latter require financial outlays, many of the former do not, requiring only commitment to safety and quality.
The cognitive factors in diagnostic errors include the doctor’s training, experience and predisposition to biases, as well as fatigue and stress.
There should be encouragement and rewards for continuous development of doctors’ skills and for addressing their unconscious bias in clinical judgement.
Last, but not least, patients should be supported in active engagement throughout their diagnostic journey.
The World Health Organization (WHO) has called for the worldwide lighting of monuments on Sept 17 to cast an orange glow across the globe to highlight the importance of correct and timely diagnosis for patient safety.
Let us light up buildings, landmarks and monuments into beacons of humankind’s shared commitment to diagnostic safety!
Dr Milton Lum is a past president of the Federation of Private Medical Practitioners Associations and the Malaysian Medical Association. For more information, email starhealth@thestar.com.my. The views expressed do not represent that of organisations that the writer is associated with. The information provided is for educational and communication purposes only, and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.
