Graber, Mark Mark.Graber at VA.GOV
Thu Apr 24 02:12:42 UTC 2014

There's no question that we will never find all the diagnostic errors, nor will be ever be able to fix them all.  Both are interesting topics for discussion, but I would not want to see this existential angst give anyone the wrong impression.

We certainly CAN find and count some important fraction of these errors and I believe we can do so reproducibly and with sufficient reliability to allow for real performance improvement projects to be based on these measurements.  It would not be that difficult, as an example, to follow up with every patient seen in an ER over a 6 month period with complaints of abdominal pain to determine what fraction ended up with the wrong or a delayed diagnosis, using some standard definition.  Or Hardeep's approach can be used as a measure of the diagnostic error rate in primary care - its not perfect but its very usable.

The lack of agreement on definitions, and the impossibility of finding every last error does not mean that the question can't be studied.

From: <Ted.E.Palen at KP.ORG>
Reply-To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>, <Ted.E.Palen at KP.ORG>
Date: Wed, 23 Apr 2014 16:54:16 -0400

Hi all
It is very hard if not impossible to know the "true diagnostic error rate."  That is because we will never know the true numerator. Patients are lost to follow-up, do not report back if symptoms resolve but the original diagnosis was wrong, or signs and symptoms persist and present as different diagnosis and if they see a different physician without prior information may never know a previous diagnosis was made.  Therefore, we will never know the true number of diagnostic errors.

Ted E. Palen, PhD MD, MSPH | Physician Investigator | Institute for Health Research | Kaiser Permanente Colorado
Physician Manager for Clinical Reporting | Medical Cost Management| Colorado Permanente Medical Group
* 303-614-1215 | 7 303-614-1305 | * ted.e.palen at kp.org <mailto:sarah.madrid at kp.org>

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From:        Ross Koppel <rkoppel at SAS.UPENN.EDU>
Date:        04/23/2014 01:04 PM
Subject:        Re: [IMPROVEDX] [EXTERNAL] [IMPROVEDX] quick ?


First, I want to second Mark's comment.  It very much depends on the
methodology used.  Hardeep's methodology (as all methods) is limited to
the parameters he used (charts, return visits, etc).  While fine
research (he's one of my heroes), it cannot be representative of the
larger error rate, which would have to reflect the conditions that were
unknown and did not appear in charts or in subsequent revisits or
re-admits. I don't know what that ratio is, but it's non-trivial.  Very
non-trivial.  Then, of course, as has been argued here, there's the
definition of Dx error.  If it's delayed to the point that something
could have been done but was not, that's different than if it took a few
years but made no difference.


Ross Koppel, Ph.D. FACMI
Sociology Dept and Sch. of Medicine
Senior Fellow, LDI, Wharton
University of Pennsylvania, Phila, PA 19104-6299
215 576 8221 C: 215 518 0134

On 4/23/2014 1:32 PM, Graber, Mark wrote:
> Stephen,
> We (I) believe the risk of diagnostic error in general medical settings in the US is in the range of 10 - 15%  (Graber.  The Incidence of Diagnostic Error in Medicine;  BMJ Qual Saf 2013;22:ii21-ii27. doi:10.1136/bmjqs-2012-001615).  That's all errors, most of which (thankfully) are inconsequential or caught.  The risk of harm is clearly much less and its hard to put a number on that.
> The news stories centered on Hardeep's recent article  ( The frequency of diagnostic errors in outpatient care: estimations from three large observational studies
> involving US adult populations.  Singh H, et al. BMJ Qual Saf 2014;0:1-5. doi:10.1136/bmjqs-2013-002627) where they identified a risk of approximately 5% from chart reviews in primary care clinics.  That number is in the 10-15% ballpark, given that the approach would have missed errors that weren't obvious from the medical record, and errors for which the consequences played out elsewhere, and other methodologic issues.
> All of these numbers are based on research approaches.  So far, there aren't any healthcare organizations I know of that are measuring error rates in real time, and the challenges of actually doing this are substantial.  We have little data on the error rate for surgical patients, or patients seen in the ER.  There is a great need for research on this question, and for finding reliable and reproducible ways to find and count these errors going forward.  You can't improve what you can't measure.
> Mark
> Mark L Graber, MD FACP
> Senior Fellow, RTI International
> Professor Emeritus, SUNY Stony Brook School of Medicine
> Founder and President, Society to Improve Diagnosis in Medicine
> Phone:   919 990-8497

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