DENISE NEAL, BSN, MJ, CPHRM, DFASHRM
Assistant Vice President, Risk Management Group
AWAC Services Company, a member company of Allied World

According to the Society to Improve Diagnosis in Medicine, “Inaccurate or delayed diagnosis is one of the most important safety problems in healthcare today and inflicts the most harm”.¹ It is likely that every one of us will experience a diagnostic error at least once in our lifetime.²  “One-third of malpractice cases that result in death or permanent disability stem from inaccurate or delayed diagnosis”.³ Psychiatrists must educate themselves and continue to conduct research regarding diagnostic error in psychiatry to help reduce the incidence of diagnostic errors in their field.

Why Does Diagnostic Error Exist?

Diagnostic error is the failure to establish an accurate and timely explanation of the patient’s health problem(s) or communicate that explanation to the patient.⁴ Diagnosis is an intricate process that occurs within a complex work system and there is no easy fix to this problem. Diagnostic error can occur at any time through the diagnostic process (Information gathering, initial diagnostic assessment, testing, results processing, follow up, and care coordination). As you can imagine, diagnostic errors are also difficult to measure.

Diagnostic error claims include misdiagnosis with harm resulting from the delay or failure to treat a condition. There are many factors that can contribute to diagnostic errors. These errors can be caused by both system-related and cognitive factors including but not limited to:

• Fragmentation of care due to patients receiving healthcare from multiple physicians, specialists, and providers, at multiple locations
• Inadequate communication and collaboration among the care team, consultants, patients, and their families
• Patient factors such as the patient’s health literacy; cultural factors, for example related to sharing of information; patient’s actions such as failure to follow treatment recommendations/complete ordered tests
• Affordability and access to care; and availability of resources such as the internet
• Time, which can be a factor.  Most diseases evolve over time and symptoms may not be recognized.  On the other hand, some diagnoses must be diagnosed immediately to prevent harm such as stroke
• Bias which can come in many forms such as confirmation bias, anchoring bias, affect heuristic, and premature closure ^5,6
• A narrow diagnostic focus
• Supply chain or resource issues
• Limited availability of diagnostic testing, misinterpretation of diagnostic studies, or failure or delay in ordering tests
• A chaotic work environment (distractions)
• An organizational culture that is punitive or lacks a Culture of Safety⁷
• Staffing issues including the limited availability of specialists
• The knowledge, experience, and skill of providers, as well as the resources available to them
• Burnout or alert fatigue
• Computer systems such as lack of interoperable electronic health records systems

Strategies to Avoid Diagnostic Error

Obtain a Thorough Patient History and Mental Status Exam Before Making a Diagnosis

Errors in diagnosis may occur when the psychiatrist does not have all the necessary information to make an accurate diagnosis. There can be many factors that get in the way of obtaining this adequate information. Time to gather the information and consultation with the patient may be limited due to insurance, and other financial constraints. Clinical factors may interfere with information gathering from a patient due to the patient’s anxiety, poor memory and concentration, disorganized thoughts, or attempts at manipulation.⁸ The patient may also fail to share information due to shame, guilt, or fear of legal consequences.⁹

Another barrier that often comes up is the lack of authorization to speak with other treating providers, for example the patient’s current or former psychiatrist, psychologist, or PCP. Refusal of the patient to authorize the psychiatrist to speak to other providers should be a red flag to psychiatrists entering into a treatment relationship. The lack of authorization to speak to treatment providers interferes with the ability to collaborate and/or coordinate care and to make an accurate diagnosis. Before starting a treatment relationship with a patient who will not provide authorization to obtain medical records, or speak with current or former treating providers, consider whether you will be able to enter into a mutual agreeable and trusting relationship without this information.

It is important to obtain an authorization to review medical records and speak to current and former treating providers, and when appropriate obtain authorization to review school records, and speak with the patient’s family. Be mindful to maintain a current authorization to ensure you can continue to communicate with current treating providers and the patient’s family. For adolescents reaching the age of majority, have discussions with the patient and parent/guardian regarding the need for a new authorization when the patient turns 18.

There are risks regarding obtaining a thorough mental status exam especially through telehealth. It is important for the psychiatrist to determine whether the patient may be appropriate for an assessment through telehealth or if an in-person exam is required. Once care via telehealth is established, the appropriateness of the use of telehealth should continually be assessed.

Look at the Big Picture

Clinical judgement is the leading cause of malpractice claims which may be caused by cognitive bias, clinical reasoning, and knowledge gaps.¹⁰  Learning about vulnerabilities within the diagnostic process may help psychiatrists to reduce diagnostic error rates. Diagnosis in psychiatry is both complex and difficult as many conditions mimic one another.¹¹ According to Caroline Balling MD, one study found two-thirds of patients diagnosed with bipolar disorder were misdiagnosed during initial treatment.¹² Some symptoms may be present in multiple disorders. For example, Complex Post-Traumatic Stress Disorder (cPTSD) may appear to be a basic anxiety disorder, mood disorder, attention deficit disorder, or anger management issues.^13,14

Physicians must be mindful to avoid possible confirmation bias and anchoring bias when making a diagnosis.¹⁵ Keep this in mind when a patient comes to the office and reports having a particular diagnosis based on popular diagnoses such as depression, PTSD, and Attention-Deficit / Hyperactivity Disorder (ADHD) after conducting a “Dr. Google” search. Recognize and educate the patient that symptoms may be present in more than one diagnosis and that further information, testing, referrals, and sessions may be necessary to come to an accurate diagnosis.

Terminate Patients from Care when Appropriate

Psychiatrists often face situations when care and treatment is outside of their scope of practice; the patient requires a higher level of care than the psychiatrist can provide; or a patient/parent/guardian does not accept a diagnosis and/or adhere to treatment recommendations.  Psychiatrists in these situations often find themselves providing “some” care to the patient rather than terminating the patient, which can increase the risk of a missed or delayed diagnosis and/or treatment related errors.

Some examples of this scenario include diagnosis and treatment for substance use disorders, eating disorders, or ADHD. For example, a psychiatrist may find that a patient with a substance use disorder resists going to an inpatient/outpatient addiction treatment program. A patient with an eating disorder may refuse to be weighed or refuse hospitalization or partial hospitalization when recommended. Parent(s) may disagree regarding their child’s ADHD diagnosis or medication treatment when it is clearly indicated, or one parent agrees with medication treatment and the other does not. In these situations, termination of care should be considered early to avoid continued care that does not meet the standard of care.

Patients who are resistant to accept the diagnosis and/or adhere to the treatment plan often are also resistant to follow up on the psychiatrist’s referral, which may lead to the provider continuing to treat the patient despite the recommendation to follow up elsewhere. It is important to document each informed consent/refusal of care discussion and follow any reporting mandatory reporting obligations related to minors, to avoid allegations of improper treatment, including failure or delay in obtaining a consultation or referral, or failure to appreciate and reconcile relevant signs, symptoms, or test results.  This information is also important to show reasons for termination and will help the psychiatrist avoid an abandonment claim.

Communication

Communication amongst the healthcare team is important.  Discussion with the patients treating providers may be necessary when a patient enters or leaves a hospital, or when multiple providers are treating the same patient such as a psychiatrist, psychologist and PCP. Communication should be ongoing when the patient is doing well as well as when there is a condition change, and this communication should be documented in the medical record.  It is important to be clear regarding the role of each provider in treatment and follow up especially for patients on high-risk medication (black box warnings) or with high-risk conditions (suicidality).  Who is responsible for the continued follow up with the patient regarding required testing? For example, is it the PCP ordering blood work and EKG to monitor the patient on prescribed medication or is it the psychiatrist?  Who is responsible for ensuring the patient has the bloodwork completed and who is ensuring the results are received? This responsibility can become unclear when a patient is on a medication for a long period of time, especially if more than one provider has prescribed the same medication for the patient. Establish routine follow-up intervals and monitoring expectations when there are multiple providers involved.

Resources

Although the causes of diagnostic error are complex, there are many free resources and tools available to psychiatrists and members of the healthcare team to continue to educate themselves with a goal of improving patient safety.

• The Society to Improve Diagnosis in Medicine has free resources available on their website including publications, reports, whitepapers, webinars, tools, and toolkits to help clinicians improve diagnosis and eliminate harm from diagnostic error.¹⁶
• The National Academies of Sciences, Engineering and Medicine publication Improving Diagnosis in Health Care.¹⁷  This publication is a continuation of the landmark Institute of Medicine reports To Err Is Human (2000) and Crossing the Quality Chasm (2001) finds that diagnostic errors have not been appreciated.  The report discusses diagnosis and diagnostic errors and provides eight goals to improve diagnosis and reduce diagnostic error.
• The Agency for Healthcare Research and Quality (AHRQ) has information available in common formats for providers and organizations to help collect, aggregate, and analyze diagnostic safety-related information nationally to accelerate learning and improvement.¹⁸
• The AHRQ recently developed a tool called “Measure Dx” to help clinicians and others identify diagnostic safety events and gain insights for improvement.¹⁹
• The AHRQ has a free Diagnosis Improvement course that applies the TeamSTEPPS^® framework to diagnostic error.  “TeamSTEPPS^® for Diagnosis Improvement aims to raise diagnostic safety awareness, introduce the concept of a broad multidisciplinary diagnostic team that includes non-clinicians and patients and their families, and provide assessment and training tools to support local efforts to reduce diagnostic harm.”²⁰
• There are also medical record review tools specific to diagnostic error to help identify diagnostic error in practice.²¹

Conclusion

Inaccurate or delayed diagnoses occur in all settings of care and continue to harm patients in alarming numbers. It is important for psychiatrists to continue to learn about diagnostic error with a focus on improving diagnosis and eliminating harm. Individual learning and collaboration with members of the healthcare team, patients, and other key stakeholders will help to improve diagnostic quality and safety, reduce harm and ultimately, ensure better health outcomes for patients.