Patient safety experts from Johns Hopkins University in Minnesota say it’s high time for diagnostic errors to get the same attention as drug-prescribing errors, wrong-site surgeries and hospital-acquired infections. Their prescription for reducing the number of diagnoses that are missed, wrong or delayed includes the checklist. This humble tool has proven itself for decades as an ergonomic way to improve safety, particularly in the aviation field, but it has found little favor in the medical field. Two recent initiatives could win over skeptics.
Diagnostic misadventures represent a potentially much larger source of preventable health problems and deaths than many of the more popular targets of safety reform, say David Newman-Toker MD, Ph.D., and Peter Pronovost MD, Ph.D., in the March 11 issue of the Journal of the American Medical Association (JAMA). The Johns Hopkins team reports that misdiagnosis accounts for an estimated 40,000 to 80,000 hospital deaths per year and that tort claims for diagnostic errors — defined as diagnoses that are missed, wrong or delayed — are nearly twice as common as claims for medication errors.
The doctors suggest that diagnostic errors might be reduced by systematically adopting tools such as checklists that help physicians remember critical diagnoses or by making available computer programs known as “diagnostic decision-support systems” that assist physicians in calculating the level of risk of a given patient’s having certain diseases. Health systems could further decrease diagnostic errors, they say, with time-tested, low-tech tools such as independent second looks at X-rays and CT scans or rapidly directing patients with unusual symptoms to diagnostic experts.
A new national safety initiative puts the checklist tool to work to save lives in hospital intensive care units (ICUs). Launched across 30 states in 2009, the National Implementation of the Comprehensive Unit-Based Safety Program (CUSP) to reduce Central-Line Associated Blood Stream Infections (CLABSI) in the ICU is based on a checklist created by Dr. Pronovost. The program will continue through September 29, 2011. It could save some $3 billion dollars and 30,000 lives each year, according to the university’s news release.
A recent pilot program demonstrated its effectiveness. The program ran in 77 hospitals and 103 intensive care units in Michigan for 18 months, and infections rates dropped 66 percent, according to Dr. Pronovost. “As a result, $200 million and an estimated 2,000 lives were saved. I’m confident we’ll see a similar result nationwide.”
The checklist contains five important steps that need to be followed when placing a central line catheter. This type of catheter is used regularly for patients in the ICU to administer medication or fluids, obtain blood tests, and directly gauge cardiovascular measurements such as central venous blood pressure. Each year, roughly 80,000 patients become infected and 30,000 to 60,000 die at a cost of $3 billion nationally.
The influential World Health Organization is convinced checklists represent a sound direction, and released the Safe Surgery Checklist in 2008. In a 14 January 2009 news release it noted that hospitals in eight cities around the globe have successfully demonstrated that “the use of a simple surgical checklist … during major operations can lower the incidence of surgery-related deaths and complications by one third.”
Though the benefits appear significant, there is no guarantee the medical culture will embrace the checklist. Exploring some of the obstacles in the March 18 issue of The Ergonomics Report®, a publication for subscribers with a professional interest in ergonomics and human factors, it notes that the tool is viewed as a nuisance and a distraction by some doctors.
Dr. Pronovost has no doubts about their value. His next step is to apply checklists to other health care problems, such as methicillin resistant staphylococcus aureus (MRSA), and vancomycin-resistant enterococcus (VRE). He notes that illnesses caused by these bacteria are among the most common health care-acquired infections in the United States, affecting one in 10 patients, killing approximately 90,000 individuals and costing between $5 billion and $11 billion annually.
Sources: Johns Hopkins University, The Ergonomics Report®