Diagnostic Errors and Patient Safety Practices

Diagnostic errors typically fall into one of three groups: an incorrect diagnosis, a delayed diagnosis, or the failure to make any kind of diagnosis. Researchers from Johns Hopkins University School of Medicine have found that diagnostic errors make up a significant fraction of all claims. The researchers estimate that there are between 80,000 and 160,000 preventable deaths in the United States each year due to diagnostic errors. Along with the cost in lives, there are financial costs as well; the estimate is $38.8 billion in malpractice payouts between 1986 and 2010.

Diagnostic Errors are Hard to Track

While there has been a significant amount of attention placed on mistakes in surgery and errors in prescribing medication, diagnostic errors have largely been overlooked. One of the reasons is that they are often difficult to track since a significant amount of time can pass between the error and the time that its consequences are discovered.

The Missed Diagnosis

The most common type of diagnostic error is the missed diagnosis. According to the leader of the Johns Hopkins study, this type of error occurs where medical personnel know enough to make the correct diagnosis, but fail to do so. Compared to surgical and medication errors, missed diagnoses tend to be subjective. Adding to this problem is the high cost of testing. Doctors are forced to make a choice between ordering more tests and potentially making a wrong diagnosis.

A missed diagnosis does not always indicate negligence. Even highly skilled physicians providing reasonable care can make mistakes. The key to determining whether the doctor was negligent is to evaluate what steps they took to arrive at their diagnosis. A preliminary examination of the patient should provide a doctor with a list of several possible diagnoses; the list should then be narrowed down with testing. In a best-case scenario, only one diagnosis from the list will remain at the end; however, the list may be lengthened or thrown out altogether as testing progresses.


Anesthesiologists Say Not all Tests are Always Necessary

The American Society of Anesthesiologists, also known as the ASA, assert that patients who are suffering from chronic pain should question certain tests and treatments being put forth on them. Overall, the ASA claims that individuals who suffer chronic pain that is not related to cancer should not be required to undergo MRIs, X-rays and CT scans. These tests are commonly ordered but are not always necessary for such patients.

In addition, the ASA says that opioid analgesics should not be administered or prescribed to patients suffering from chronic pain that is not related to cancer. Instead, it asserts, doctors should consider a different type of treatment that does not involve drugs. These include behavioral and physical therapy that can be tried as alternatives prior to the use of pharmaceutical drugs. In the event that medication is recommended, the ASA recommends that non-opioids be used first.

In general, the ASA does not recommend prescribing opioid analgesics as a long term medication to treat chronic pain that is unrelated to cancer, at least until the risks are discussed with the patient. In addition, the patient should always be advised and informed of any and all risks of this type of treatment and the potential for developing an addiction as a result of taking these drugs. Doctors are always required to inform patients about any adverse side effects of low testosterone and estrogen or constipation.

The ASA also recommends that doctors avoid prescribing imaging studies on patients for acute low back pain unless they receive specific indications to do so. They should be avoided at least within the first six weeks after the patient’s pain starts unless there is a belief of cancer.

Intravenous sedation for a nerve block or joint injections is also advised against and should not be used as an automatic standard practice. The ASA states that such procedures as sedation should be done with anesthesia alone.

Irreversible interventions should also be avoided when dealing with patients experiencing non-cancer pain. These treatments include peripheral radiofrequency ablation and peripheral chemical neurolytic blocks, which can lead to long term weakness, numbness or increased pain in a patient that is irreversible.


Alaska Passes An I’m Sorry Bill for Medical Malpractice

In an attempt to reduce the number of medical malpractice cases brought in the state, Alaska lawmakers have passed a bill that would make apologies from doctors to injured patients and their families – due to doctor or hospital error – inadmissible in a court of law.

The right to file a medical malpractice lawsuit is not in question. All sides agree that a patient’s ability to sue puts the power of health care delivery where it clearly belongs – in the hands of the patient. The issue at the heart of the Alaska statute is whether a doctor’s apology should be admissible in the event a suit is ultimately filed. The bill clearly states that any expression of apology or sympathy made along with an admission of liability or negligence would still be admissible. Proponents of the Alaska law point to studies showing it has resulted in significant cost savings in other states.

Still, “I’m sorry” laws continue to be the subject of much debate – not surprising when one considers the often conflicting needs of the various parties involved. Patients (and their families) want to be able to sue for damages when there has been injury or death due to negligence. The insurance industry wants limits placed on what constitutes the legal basis for a malpractice suit, but they are sometimes criticized for wanting to limit patients’ rights. Of course, doctors and healthcare providers want lower malpractice insurance rates.

Lawyers on both sides have a financial incentive to facilitate and defend lawsuits. In fact, many believe that the rising costs associated with medical malpractice are not a problem at all. They point to a review of malpractice claims by Johns Hopkins researchers indicating that those costs “added up to roughly $1.4 billion a year, making up far less than 1 percent of national medical expenditures in the United States.”

The American Medical Association states that when a patient suffers significant harm due to negligence, “the physician is ethically required to disclose to the patient all the facts necessary to ensure understanding of what has occurred.” While most physicians would agree with this principle in theory, full disclosure has not always been the norm. [3]

In theory, as long as a doctor does not admit to negligence, nothing the doctor says would be admissible in court. In reality, however, there is often a thin line between an apology for the fact that something went wrong and an admission of negligence. While “I’m sorry” laws enacted in other states have led to the number of malpractice lawsuits filed, doctor’s will still have to be prepared to at least occasionally walk that thin line.


Healthcare-Acquired Infections: CDC Stats

The Centers for Disease Control and Prevention has recently reported that a staggering one out of every 25 patients in hospitals fall ill with healthcare-associated infections. The report was issued the last week of March 2014 and was published in the New England Journal of Medicine.

busy hospital corridor

The CDC came to its conclusion after reviewing patient data acquired from 183 hospitals in 2011. The results showed that nearly 721,800 healthcare-associated infections afflicted 648,000 patients who were hospitalized and that 75,000 of the individuals died as a result of their illnesses. The largest percentage of patients who got ill were those who had gotten surgery, at 22 percent. Pneumonia infections accounted for the same number. Seventeen percent of patients developed gastrointestinal, 13 percent urinary tract, and 10 percent bloodstream infections as the most commonly acquired healthcare-associated infections at hospitals.

The CDC issued a separate report that asserts that progress is being made to prevent risks of developing infections while in the hospital. For example, it was revealed that between 2008 and 2012, bloodstream infections through central lines decreased by 44 percent and surgical site infections decreased by 20 percent. An additional report revealed that between 2011 and 2012, MRSA and C. difficile infections decreased by 4 percent and 2 percent.In addition, the CDC reported that infections that tend to be the most commonly spread at hospitals are Clostridium difficile at 12 percent, staphylococcus at 11 percent, klebsilella at 10 percent, E coli. at 9 percent, enterococcus at 9 percent and pseudomonas at 7 percent.

Although the progress reports show great improvement in the prevention of these infections in patients at hospitals, the CDC acknowledges there is a lot more work to be done to protect patients from healthcare-associated infections that are preventable.

CDC Director Tom Frieden, MD, MPH, stated that clinicians have to prevent infections by the most basic means, such as washing their hands. He asserted that even the most advanced techniques are ineffective if basic hygiene is not practiced and that standard infection control must be used to ensure the safety of patients.


Missouri Seeks Cap For Medical Malpractice Damages

A Missouri House committee recently endorsed a new law that would put a limit on the awards from medical malpractice suits. The law would cap non-economic awards to a mere $350,000. The cap won’t affect factors like lost income or medical expenses.

Those supporting the bill claim that it’s needed to prevent malpractice insurance costs from increasing dramatically and forcing many physicians to leave the state or close their practices. Those opposing the bill claim the law would let irresponsible doctors get away with malpractice.

Republican Representative Bill White from Joplin, MO says that, if left unchecked, large malpractice awards will force doctors and hospitals to pay higher premiums, inflate already-bloated medical costs, and make it harder to attract doctors to risky fields like neurosurgery.

Representative White promoted a bill to change the Missouri constitution to allow the Legislature to put limits on non-economic malpractice awards. Instead of voting on White’s proposal, the committee accepted a similar proposal brought forth by Republican Representative Eric Burlison of Springfield.

Between 2005 and 2012, Missouri already possessed laws to limit non-economic malpractice damages, until they were declared unconstitutional by the Supreme Court. Tim Jones, the Republican House Speaker, claims that putting the limits back into effect was among his highest priorities this session.

However, those who oppose the cap believe it would become harder for people to file malpractice suits. David Zevan, a medical malpractice lawyer from St. Louis, says that while he respects doctors, he doesn’t think it was okay to cover up the issue of malpractice.

Mr. Zevan once represented a woman who was a retired teacher. The woman lost an eye after surgeons operated on the wrong one. Because she was retired and had later received the correct operation, her lost eye was considered non-economic damage.

Mr. Zevan said, “It’s shocking. If they reinstate the limit, I’ll have to tell her, ‘I’m sorry, but not long ago, the law preemptively determined how much your lost eye was worth.’ That’s not fair to her.”

House Speaker Tim Jones said, “My party in the Senate needs to be held accountable and decide whether they really want to repair the state’s healthcare crisis. We hope this will become a bigger priority and that it’ll make it to the governor’s desk or to a public vote.”

The committee held a hearing on the bill last month, but so far has not voted on it. Rep. Eric Burlison feels that the proposal is merely a distraction and there will be another push for higher limits. However, he claims that other states with this sort of law had set the cap even lower than Missouri’s.