New Attention Being Directed toward Diagnostic Adverse Events (DAEs)
Posted Jul 15 2010 12:00am
The definition for an "adverse event" appears to be broadening to include problems beyond those associated with drug administration. Here is an example of such a broader definition that I encountered: An unexpected medical problem that happens during treatment with a drug or other therapy. Adverse events do not have to be caused by the drug or therapy, and they may be mild, moderate, or severe. To make things even more interesting, the term adverse event is also logically being split into two subcategories: diagnostic adverse events and therapeutic adverse events. An recent study of the former has revealed that they can have serious consequences (see: Diagnostic Adverse Events Mostly Caused By Human Error ). Below is an excerpt from this article:
Diagnostic adverse events (DAEs) have severe consequences, are mostly caused by human error, and may be preventable, according to the results of a medical record review reported in the June 28 issue of the Archives of Internal Medicine....Trained physicians in 21 hospitals across the Netherlands reviewed a total of 7926 randomly selected patient records, using a protocol developed by the Harvard Medical Practice Study....DAEs were identified in 0.4% of hospital admissions, accounting for 6.4% of all AEs. Of these DAEs, 83.3% were thought to be preventable, with the predominant cause being human failure in 96.3%, contributing organizational-related factors in 25.0%, and patient-related factors in 30.0%. Compared with other types of AEs, the consequences of DAEs were more severe, with a mortality rate of 29.1% vs 7.4%."Diagnostic AEs represent an important error type, and the consequences of DAEs are severe," the study authors write. "The causes of DAEs were mostly human, with the main causes being knowledge-based mistakes and information transfer problems. Prevention strategies should focus on training physicians and on the organization of knowledge and information transfer."
I find in very useful. in order to understand DAEs, to define the term as late or wrong diagnosis for a patient. On this basis, it easier to understand the mortality rate of 29.1% that is associated with them as noted above, particularly if a patient is acutely ill. Little good will come from the treatment of a patient on the basis of a wrong or late diagnosis. This point strongly underscores my view of the criticality of the diagnostic process and the consequences when it goes awry. The key question, then, is how and why it goes awry.
Pathologists and radiologists have a pivotal role to play in the reduction of DAEs. The article quoted above is quite specific about how to correct the problem: The causes of DAEs were mostly human, with the main causes being knowledge-based mistakes and information transfer problems. Prevention strategies should focus on training physicians and on the organization of knowledge and information transfer. We can do little to correct a "knowledge problem" on the part of a clinician who has received timely and correct diagnostic reports from pathology and radiology. However, there is much work to be done in terms of timely reporting from these two diagnostic services and also better integration of the diverse diagnostic reports from them.
In past notes, I have commented on the integration or merger of pathology, clinical pathology, and radiology into a new discipline of diagnostic medicine . A key element in this proposal is the development of the integrated diagnostic report. Ideally, such a report would consist of "sub-reports" or "report segments" such as a set of serum biomarkers, a CT scan, or the interpretation of a tissue biopsy. At the end of each integrated report, a global interpretation/diagnosis could be appended based on all diagnostic studies and tests (e.g., tissue, imaging, serum) to date for that patient for that episode of care. The challenge of creating such an integrated report is that few pathologists or radiologists today would have the ability to create it. However, I am also aware of the irony of such a statement because we expect every single clinician who is the recipient of such a broad array of diagnostic reports to perform this very integrative function.
The definition for an "adverse event" appears to be broadening to include problems beyond those associated with drug administration. Here is an example of such a broader definition that I encountered: An unexpected medical problem that happens during treatment with a drug or other therapy. Adverse events do not have to be caused by the drug or therapy, and they may be mild, moderate, or severe. To make things even more interesting, the term adverse event is also logically being split into two subcategories: diagnostic adverse events and therapeutic adverse events. An recent study of the former has revealed that they can have serious consequences (see: Diagnostic Adverse Events Mostly Caused By Human Error ). Below is an excerpt from this article:
I find in very useful. in order to understand DAEs, to define the term as late or wrong diagnosis for a patient. On this basis, it easier to understand the mortality rate of 29.1% that is associated with them as noted above, particularly if a patient is acutely ill. Little good will come from the treatment of a patient on the basis of a wrong or late diagnosis. This point strongly underscores my view of the criticality of the diagnostic process and the consequences when it goes awry. The key question, then, is how and why it goes awry.
Pathologists and radiologists have a pivotal role to play in the reduction of DAEs. The article quoted above is quite specific about how to correct the problem: The causes of DAEs were mostly human, with the main causes being knowledge-based mistakes and information transfer problems. Prevention strategies should focus on training physicians and on the organization of knowledge and information transfer. We can do little to correct a "knowledge problem" on the part of a clinician who has received timely and correct diagnostic reports from pathology and radiology. However, there is much work to be done in terms of timely reporting from these two diagnostic services and also better integration of the diverse diagnostic reports from them.
In past notes, I have commented on the integration or merger of pathology, clinical pathology, and radiology into a new discipline of diagnostic medicine . A key element in this proposal is the development of the integrated diagnostic report. Ideally, such a report would consist of "sub-reports" or "report segments" such as a set of serum biomarkers, a CT scan, or the interpretation of a tissue biopsy. At the end of each integrated report, a global interpretation/diagnosis could be appended based on all diagnostic studies and tests (e.g., tissue, imaging, serum) to date for that patient for that episode of care. The challenge of creating such an integrated report is that few pathologists or radiologists today would have the ability to create it. However, I am also aware of the irony of such a statement because we expect every single clinician who is the recipient of such a broad array of diagnostic reports to perform this very integrative function.