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.