Diagnostic errors: Why they happen

My lede:

Within five years, Susan Sheridan’s family was devastated by two diagnostic errors. The first came in 1995, when her newborn son Cal’s early development of jaundice — a red flag for the potential of the severe neurological disorder kernicterus — fell through the gaps in the system despite repeated attempts to alert physicians and other health professionals. As a result of delayed treatment, Cal developed cerebral palsy and has dealt with several other neurological problems.

Then in 1999, Sheridan’s husband, Pat, was told that the mass discovered in his cervical spine was benign. Six months after an apparently successful surgery to remove the mass, Pat again required surgical intervention. This time, physicians said the fist-size tumor was malignant.

But when Sheridan checked her husband’s medical chart, she was shocked to discover a pathologist’s report issued 21 days after the first surgery. The report said that first mass was malignant.

“My knees buckled,” said Sheridan, co-founder and president of Consumers Advancing Patient Safety, a Chicago-based patient advocacy organization. “It was unbelievable to me that a second significant gap in the health care system had tragically impacted my family. It was a double whammy, and it made me realize how very, very fragile our health care system is.”

The pathologist’s report apparently never made it to the neurosurgeon caring for Pat, who died after three agonizing years with spinal cancer and many more surgeries.

Diagnoses that are delayed, wrong or missed entirely result in 40,000 to 80,000 U.S. hospital deaths annually, according to research estimates. About 5% of autopsies find clinically significant conditions that were missed and, if treated, could have resulted in the patient surviving the hospital stay. Meanwhile, about 40% of medical liability lawsuits involve diagnostic errors. Nearly one in three reported adverse events involve diagnostic errors, and more than 10% of these mistakes result in death.

For the Sheridan family, two kinds of diagnostic errors resulted in calamity. In Cal’s case, a series of cognitive errors — not realizing that early-onset jaundice could be a sign of something much worse — was to blame. And a system error — failing to properly communicate a critical test result — was at fault in Pat’s case.

Experts say these two kinds of mistakes often conspire to make diagnostic errors a daunting patient-safety challenge. Fledgling efforts are under way to understand how these errors, which strike at the heart of the physician’s craft, happen and to find ways to prevent them.

Read the whole shebang.