Pathway to reducing medical errors

By Jason B. Lee, MD, FAAD
June 26, 2024
Vol. 6, No. 26

The 2000 landmark report by the Institute of Medicine To Err Is Human: Building a Safer Health System ushered in the patient safety movement in the modern era. (1) The report highlighted nearly 98,000 hospital deaths a year due to medical errors. Faulty processes and systems in the care environment accounted for over half of the deaths. Patient safety and quality improvement are now regular activities of residency training programs where a team approach in the prevention of errors is emphasized rather than the blame-shame-discipline culture of the past.

Borne out of this new culture of safety, Huang and colleagues reported errors encountered in a dermatopathology laboratory over a one-year period. (2) The errors were categorized into the incident type, source of error, stage of occurrence, who caught the error, and type of error. An overall error rate of 0.7% was observed, which translated into 190 errors during the year while 25,662 specimens were processed. Incorrect biopsy site (n=65) and specimen mix-up (n=23) occurred mostly at the clinical level, including 6 where there was no specimen in the bottle. The study confirms that errors in the diagnostic pathway are the biggest source of errors in dermatology practices as reported in the past. (3) An estimated 20 handoffs occur in the biopsy pathway in which errors may occur in each step. (3,4) Recommendations to reduce medical errors include establishing a safety team to perform a root cause analysis whenever an error occurs, with the goal of improving the workflow to make it harder for errors to occur during the diagnostic pathway. (5-7) The study highlights the importance of using checklists and timeouts to prevent mistakes in labeling, specimen collection, and patient identification.

Two notable errors in the laboratory included incorrect entry of a correct diagnosis (n=25, 13.2%) and diagnostic error (n=17, 9.0%), nine of which resulted in change in management. Incorrect entry of a correct diagnosis represents a type of error referred to as a slip in which correct intention resulted in incorrect outcome, usually because of inattention. In fact, slip was the most common type of error that was observed in the study, accounting for 82% (156/190) of the error type. A much less frequent type of error was a lapse, an error of omission (e.g., omission of ancillary stain result on the pathology report). The majority of the incorrect entry of a correct diagnosis was because of entry of a wrong diagnosis code, while diagnosis entry on a wrong patient comprised a minority. A system-based approach intervention may reduce slip and lapse error types. For example, implementation of a barcode scanning system may reduce diagnosis entry on a wrong patient.

In contrast to slip errors, diagnostic errors may not be amenable to a systems-based intervention. The overall diagnostic error rate was low (0.07%) comparable to other laboratory studies, but it ranked second among errors in the laboratory. (8) A complex interplay between system-based and cognitive factors results in diagnostic errors. (9) Diagnostic errors are primarily caused by faulty cognitive processes while knowledge gaps playing a lesser role, according to the studies from the cognitive disciplines of medicine. (7,10,11) The case example in the study illustrates an obvious case of tinea capitis in hindsight but diagnostic momentum, confirmation bias, and inattentional (perceptual) blindness all worked together to mislead the dermatopathologist. When the clinician suggested the diagnosis of lichen planopilaris, the dermatopathologist confirmed the presence of perifollicular fibrosis while ignoring other relevant histopathologic findings and failed to perceive the obvious hyphae in the hair shaft.

Diagnostic error has been referred to as the hidden epidemic that represents an enormous unmeasured source of preventable morbidity, mortality, and cost. (12) In 2015, the National Academies of Sciences (formerly Institute of Medicine) published a report Improving Diagnosis in Health Care that highlighted the unacceptable number of patients harmed due to diagnostic errors and suggested that improving diagnosis represents a moral, professional, and public health imperative. (13) Diagnostic error is an unpopular under-studied and under-funded subject despite the large financial and harmful impact on patients. Concerns over embarrassment, reputation, disciplinary actions, and malpractice lawsuits contribute to significant under-reporting of diagnostic errors. An untold number of diagnostic errors are left undetected, the cost and harm of which are quietly absorbed by the payers and patients. As faulty cognitive processes are largely to blame, the recommended strategies to improve diagnosis include awareness of shortcomings of our cognitive processes, metacognition, and replacing humility with overconfidence, a common trait of physicians. (10,11) These strategies may prevent some of the diagnostic errors but may have limited impact because cognitive processes in decision-making operate subconsciously and unconsciously and are not always subject to conscious control. In addition, though knowledge has been reported to contribute little to diagnostic errors in cognitive disciplines of medicine, it may play a larger role in perceptual specialties such as dermatology and dermatopathology. Experience and knowledge base may serve as a better defense against diagnostic errors in perceptual specialties.

Medical error studies such as the one by Huang and colleagues can report only the detected errors, which are an underestimate of the actual number. The magnitude of the undetected medical errors and their harm are not known. More studies are needed in the outpatient setting to develop best safe practices. In 2016, the American Academy of Dermatology developed a clinical data registry, DataDerm^™, providing a mechanism for the members to examine their practice patterns, participate in quality measures, and contribute to the needed research in the delivery of dermatologic care. (14) DataDerm at the same time serves to demonstrate value to payers and insurers, preparing the members for an eventual shift from quantity of care to a value-based care model of health care in the United States. By participating in quality improvement and patient safety activities, physicians can contribute to the creation of a safer practice environment for patients.

Point to Remember: Although the overall error rate may be low, there are specific areas and opportunities to further reduce errors in the diagnostic pathway. Being vigilant and recognizing steps prone to errors facilitates detecting errors before any potential harm comes to the patient.

Our expert’s viewpoint

David J. Birnbach, MD, MPH
Emeritus Professor, Executive Vice Provost, and Director of the UM-JMH Center for Patient Safety
University of Miami

Patient safety has come a long way since the Institute of Medicine published their ground-breaking work in 2000. (1) But not quite far enough!

Let me begin with a quick look at my life in patient safety. When I began my medical career 40 years ago the idea of patient safety was non-existent. While I trained at one of the premier academic medical centers residents were often unsupervised, attending physicians took call from home, and we worked a full day after call. Regardless of the impact on the safety of patients or ourselves, we also worked 48-hour shifts in the ICU. If a mistake occurred, the poor schnook who was deemed responsible (typically the low person on the totem pole) was brought up in front of the entire department at the Morbidity and Mortality conference and publicly humiliated, in the absurd belief that this would prevent others from making similar errors. If anyone dared complain about anything, they were reminded not to whine because there would be fewer residency spots the following year. During my first 48-hour call in the ICU, I placed a subclavian line and caused a massive pneumothorax and was told by the attending physician to place a chest tube and call him in the morning. I had seen central lines placed, but chest tubes??? Thank goodness that the fellow on call that night was only a short cab ride away (at Fenway Park watching the Red Sox lose) and came to my rescue. Also, in those days, infection was never considered. Gloves were never worn for IVs and oft times not even for arterial lines, and white jackets were worn for months until they began to appear gray. Handwashing was something done at bath time. Simulation-based education had not yet been invented (nor was the internet for that matter!) so learning was often “see one, do one, teach one.”

So that was the state of safety in the early 1980s. Asking for help — no matter what your level of experience — was frowned upon. When errors occurred, whenever possible they were swept under the rug; particularly for “near miss” events. The prevailing attitude was that if the patient wasn’t harmed or had fully recovered, there was no need to broadcast the error (such as administering the wrong drug or the wrong dose). At that time, the thought of telling anyone, especially the patient, about a medical mishap was an anathema.

Fast forwarding to the early 1990s. Dr. Lucien Leape (often called the father of patient safety) left the practice of surgery, and then at the Harvard School of Public Health fought a lonely battle to show that there are preventable errors in medical care. Unfortunately, few were listening, and those who were became shocked that one of their own became a turncoat. The prevailing attitude was that if you told patients that physicians were fallible (dare I say “human”), it would forever ruin the confidence of patients in their physicians and disrupt care. No one thought about learning from mistakes or publicizing them to help assure that the same error would not recur. Self-examination was unheard of. Leape’s NEJM papers in 1991 (15) and his JAMA expose in 1994 titled “Error in Medicine” (16) sent very temporary shock waves but not enough to heed his plea to protect patients from errors by changing existing systems. That paper, and others that followed, became the impetus for the landmark Institute of Medicine report (“To Err is Human”) announcing to the world that almost 100,000 patients in the U.S. were annually dying from medical errors. Sure, it was possible, but skeptics denied the veracity of those numbers and nay-sayers continued to argue that errors were incredibly rare and typically someone else’s fault. Although the movement started gradually, more physicians and hospital leaders started believing that change was necessary to correct imperfect systems that were trapping both the patient and medical provider. I was one of those physicians who “drank the Kool-Aid” and decided to complete an MPH at Johns Hopkins to work in patient safety to help thousands of patients rather than individuals — quite a contrast from the start of my academic career when safety was considered a curse word!

More than 20 years after the release of the seminal report, the landscape of patient safety is changing, but at a pace that most experts believe is not substantial or fast enough.

The challenge of changing a system as huge and byzantine as health care is not so straightforward, especially when the system and its stakeholders are often resistant to change. As James Reason (considered by many to be the father of human factors) stated, “we can’t change the human condition, but we can change the conditions under which humans work.” But have we?

The answer is yes, but not enough. There have been important changes, not least of which are reducing resident work hours. (I am still befuddled why it’s definitely not ok for a healthy 28-year-old to work more than 12 hours, but his 65-year-old physician supervisor can work more than 24 hours without anyone questioning it. How does that make any sense?!) Consensus bundles are more common (but they are being fought with the recalcitrant attitude of “I’ve been doing it this way for many years and it works for me, so I don’t care what your literature shows”) and uniform implementation of safety standards is progressing. Despite all the efforts and significant changes over the past 20+ years, including scientific and policy approaches, a staggering number of patients are still becoming permanently disabled or die annually from preventable human error. A major culprit is often suboptimal communication. We are not all natural communicators and in fact, some of us are terrible listeners — just ask your spouse! Think of the six dimensions of quality in health care (safe, timely, effective, efficient, equitable, and patient-centered) and ask yourself if you and your colleagues are giving all patients the highest quality care? It’s hard to answer yes at a time where reimbursement is decreasing, work hours are increasing, burnout is ubiquitous, and politicians, insurers, and bureaucrats have way too large a say in how medicine is practiced.

We can’t adequately improve safety until we also address quality. It is often said that “if you can’t measure it, you can’t fix it.” Quality assurance is the maintenance of a desired level of quality and entails the oft painful rigorous examination of individuals and departments. Putting the right processes in place and ensuring that they are implemented is an essential step toward improved medical care — of any specialty. Designing quality and safety projects (what do we need to improve?; How can it be improved?; How will we know if the project was successful?) is a good place to start.

It is not all doom and gloom. Currently, there is widespread interest in changing our health care culture in order to build safer systems. Such examples include sustaining an appropriate physical work environment and in developing redundancies in safety procedures. Most important, the realization that human error is inevitable and that better systems are necessary to reduce such errors is huge. Now, if we could only do something about disruptive behavior, we’d really see change!

1. Institute of Medicine (US). Committee on quality of health care in America. In: Kohn LT, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building a Safer Health System. National Academies Press; 2000.

2. Huang S, Patel V, Lee JB. Errors encountered in the diagnostic pathway: A prospective single-institution study. J Cutan Pathol. 2023;50(9):828-834. doi:10.1111/cup.14474.

3. Watson AJ, Redbord K, Taylor JS, Shippy A, Kostecki J, Swerlick R. Medical error in dermatology practice: development of a classification system to drive priority setting in patient safety efforts. J Am Acad Dermatol. 2013;68(5):729-737. doi:10.1016/j.jaad.2012.10.058.

4. Stratman EJ, Elston DM, Miller SJ. Skin biopsy: Identifying and overcoming errors in the skin biopsy pathway. J Am Acad Dermatol. 2016;74(1):19-26. doi:10.1016/j.jaad.2015.06.034.

5. Elston DM, Taylor JS, Coldiron B, et al. Patient safety: Part I. Patient safety and the dermatologist. J Am Acad Dermatol. 2009;61(2):179-191. doi:10.1016/j.jaad.2009.04.056.

6. Elston DM, Stratman E, Johnson-Jahangir H, Watson A, Swiggum S, Hanke CW. Patient safety: Part II. Opportunities for improvement in patient safety. J Am Acad Dermatol. 2009;61(2):193-206. doi:10.1016/j.jaad.2009.04.055.

7. Uhlenhake E, Feldman SR. Dermatological patient safety: problems and solutions. J Dermatolog Treat. 2010;21(2):86-92. doi:10.3109/09546630903085310.

8. Peck M, Moffat D, Latham B, Badrick T. Review of diagnostic error in anatomical pathology and the role and value of second opinions in error prevention. J Clin Pathol. 2018;71(11):995-1000. doi:10.1136/jclinpath-2018-205226.

9. Graber ML, Franklin N, Gordon R. Diagnostic error in internal medicine. Arch Intern Med. 2005;165(13):1493-1499. doi:10.1001/archinte.165.13.1493.

10. Ko CJ, Braverman I, Sidlow R, Lowenstein EJ. Visual perception, cognition, and error in dermatologic diagnosis: Key cognitive principles. J Am Acad Dermatol. 2019;81(6):1227-1234. doi:10.1016/j.jaad.2018.10.082.

11. Lowenstein EJ, Sidlow R, Ko CJ. Visual perception, cognition, and error in dermatologic diagnosis: Diagnosis and error. J Am Acad Dermatol. 2019;81(6):1237-1245. doi:10.1016/j.jaad.2018.12.072.

12. Graber ML, Carlson B. Diagnostic error: the hidden epidemic. Physician Exec. 2011;37(6):12-19.

13. National Academies of Sciences, Engineering, and Medicine. 2015. Improving diagnosis in health care. Washington, DC: The National Academies Press.

14. Van Beek M, Swerlick RA, Kaye T, et al. The 2022 Annual Report of DataDerm: The database of the American Academy of Dermatology [published online ahead of print, 2023 Apr 5]. J Am Acad Dermatol. 2023;S0190-9622(23)00535-2. doi:10.1016/j.jaad.2023.03.045.

15. Leape LL, Brennan TA, Laird N, Lawthers AG, Localio AR, Barnes BA, Hebert L, Newhouse JP, Weiler PC, Hiatt H. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med. 1991 Feb 7;324(6):377-84. doi: 10.1056/NEJM199102073240605. PMID: 1824793.

16. Leape LL. Error in medicine. JAMA. 1994 Dec 21;272(23):1851-7. PMID: 7503827.

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