Small changes that save lives

Without right diagnosis, patients don''t receive right treatment at right time from right hands, thus affecting the patient’s wellbeing.
Representational Pic
Representational Pic

Why are medical errors still a leading cause of death?

Diagnosis is the foundation of medicine. Without right diagnosis, patients don't receive right treatment at right time from right hands, thus affecting the patient's wellbeing. While  transforming the work environment of getting better at keeping patients safe   I fear misdiagnosis cases a lot i.e., diagnosing a patient wrongly either with the wrong disease, or misjudging  severity of illness by incorrect grading  (staging/scoring included which are usually spotted following further findings or testing or on deterioration of patient's condition.

What happens when your doctor gets it wrong? A misdiagnosis can have serious consequences on a person's health and prognosis. In a place like ours where standards  for  safe healthcare delivery system  are either lacking or not fully implemented  I wonder  how many  patients could actually be  victims  of misdiagnosis.

 Two case histories received   in my inbox, , only the tip of the iceberg.

Case 1. A 30 year young  female (name withheld), mother of two children for a self-detected breast lumpiness  reported to  a  Physician who  couldn't  feel any breast mass and  without doing further probing of patient's  armpit or around the collarbone ordered evaluation by mammogram and ultrasound. A final result of  BI-RADS  category III(  Breast Imaging-Reporting and Data System  ) interpreted as  benign,  with recommendation for further work up by biopsy. Fine needle biopsy(FNAB) done  the non-malignant category type of lesion(Atypical hyperplasia)was  reported .Patient and  family contended  on report didn't feel necessity of

seeking further advice till few months later  patient   deteriorated   with  breathing  problems and generalized weakness, breast and armpit swelling   had become more  prominent and , hard. The  family  in panic, without seeking  consultation  locally preferred to get treated   outside state  where she  was diagnosed with advanced cancer having spread to bones, lungs, not amenable to  surgery. The young patient  after   few cycles of chemo-radio therapy lost her battle with cancer.

Case 2. A n 18 year tech savvy boy  after many Physicians had  dismissed his neck swellings   as " nonspecific  enlargement" .The radiologist's sharp  scan could pick up  a sub cm lesion amongst deep structures of  neck, which is commendable  and under  high suspicion  of malignancy proceeded with risky Ultrasound guided biopsy  of neck swelling. Without a mandatory second opinion in the system the fellow  pathologist  interpreted  the slides as   benign nature of  lesion. In  this case the well informed family sought second opinion on same slides from another  Senior pathologist presently  working in private. Surprisingly malignant nature of disease was reported by him on same slides, the diagnosis was further  re- confirmed  by third opinion , patient is now undergoing rounds of chemotherapy , stable and  in and out of the hospital.

Why does it happen?

Accurate interpretation of patient signs, symptoms; and tests   is the foundation of medicine for further management. In the world of advancing technology with varied personality factors in  human –machine interface for managing patients, if system is in place there is no right to wrong answers  for  what we might call "The Decision Making Triangle", the right thing, the right way, the right time. While many of today's Clinical examinations and medical tests are accurate, a Physician may fail to identify a related or unrelated disease or judge accurately stage/severity in the given patient leading to preventable diagnostic errors which account for 6 to 17 percent of adverse events  and approximately 10 percent of patient deaths  in accredited hospitals  where second opinion is mandated for certain  risk prone areas and situations like OT or while interpreting sensitive tests. Our institutors  where QPS- Quality and Patient Safety System – has not yet taken roots, Physicians can sometimes make mistakes by concluding on certain  physical findings,   tests, or sensitive  situations during operations that something is true when it is actually false (A false positive is a "false alarm). What is more dangerous that something is reported negative when it is actually true (false negative), a test result that indicates a person does not have a disease or condition or grade when the person actually does have it, without second reviews on false negative test/ report  creates a false sense of well-being. Second opinion or review is not often sought at potentially curable stage leading to delay in diagnoses or treatment of cancer like diseases as happened in above mentioned case1,.while in false positive cases usually people take review opinions.

How can we stop making patients paying the price for misdiagnosis? This is my case  for making simple, small changes. The big question is: How health systems are made safer? Recognizing the continuing efforts of present healthcare leadership to bring improvement in patient care, there is still a great deal of work to be done especially in the important area of QPS implementation. Safe practices for better healthcare are one of longest running endorsement projects in our healthcare organizations. The all-around wisdom of "Think Big, Start Small, Act. We need to  analyze the need by reliable data  if we all put forward just one idea, the system is in a risky state would be deemed unsafe unless  QPS standards   are not fully implemented in our healthcare delivery system. My humble  appeal to our healthcare leadership is to "make simple changes that can improve QPS standards, policy procedures, evidence based best practice protocols should be in place for care providers to  follow ABC diagnosis algorithm so as not to  forget  relevant regional examination.

Dr. Fiaz Fazili, is Surgeon & leading Quality & Patient Safety Planner for Improvement ot care in hospitals.

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