At one time or another, even the most well-meaning, expertly-trained physician, nurse, or other member of your medical team will diagnose a patient incorrectly. When this happens, rather than point an accusatory finger or rattle off the repercussions, approach the error in a scientific and nonjudgmental way. Help your team member focus on how the error occurred—which will go a long way towards preventing future diagnostic errors and ensure overall patient safety. What’s more, taking a rational and methodical approach can uncover flaws in the diagnostic process that hold everyone on your medical team accountable. Here are some important points to consider.
Most misdiagnoses are associated with extenuating circumstances that contribute to the error.
While medical mistakes are often chalked up to human ineptitude, a flawed approach, or doctors or nurses getting boxed into a pattern of thinking, the reality of the situation is much more complex. Sometimes diagnosing an illness takes time to nail down and rarely does a clinician have all the information they need to determine its cause up front. Pressure to act quickly while waiting for lab results and failure by many patients to provide an accurate medical history contribute to a misdiagnosis. Inconclusive lab findings, flawed blood sampling, poor imaging results, data processing and charting errors, the possibility of a psychiatric component or overlay, and too many staff handoffs also come into play. In essence, diagnosing a patient correctly is contingent on a host of cognitive and technical variables. Rather than implicating a single staff member for a misdiagnosis, its best to retrace the diagnostic process, pinpoint the likely sources of error, and develop effective strategies to reduce them.
A team member who feels responsible for making a misdiagnosis is likely to have difficulty admitting it—which does little to get to the root of the problem or prevent future errors.
For the most part, a medical worker who makes a misdiagnosis is plagued by powerful feelings of guilt, incompetence, or inadequacy. They fear that discussing adverse events or “near misses” subjects them to professional censure, administrative blame, and lawsuits—all of which intensify personal feelings of shame. These feelings can ultimately affect job performance and in some cases destroy careers. Creating a climate of trust that encourages every member of your medical team to come forward and address their mistakes objectively without fear of public humiliation is crucial. Here are some steps to take:
- Question a staff member systematically.
- Emphasize their role in helping you uncover flaws in the diagnostic process.
- Let them know that you value their “transparency” about the misdiagnosis. Underscore how their honesty will not be met with disdain, punishment, or dismissal.
- Put everyone’s thinking under the microscope. Schedule a monthly “safe passage” meeting that welcomes and encourages transparency and freedom of expression from attending nurses, physicians, residents, managers, and directors. Discuss the misdiagnosis and ask attendees to focus on any and all things that may have led to the error, such as staffing shortages, staff experience, problems ordering diagnostic tests, patient load, time of day, patient input and feedback, etc. This forum sends the message that a clinical error is an opportunity to improve diagnostic processes and patient outcomes as opposed to assigning blame. Everyone walks away feeling supported, especially the medical professional initially “singled out” for making the wrong diagnosis.
Many misdiagnoses occur when a clinician becomes too firmly anchored in a particular thought process—even when new data emerges that calls for an adjustment in diagnostic thinking. Paradoxically, in an effort to not miss a diagnosis, a clinician might over-rely on test results even when those results are discordant with their experience and intuition. Helping your team member understand how pitfalls in reasoning can cloud judgement will give them confidence to hold back from putting patients through unnecessary testing and potentially harmful interventions when the diagnosis is clear, and push harder when they sense that something in the diagnostic picture does not fit. In cases of misdiagnosis suggest that your clinician deconstruct their clinical thinking to see where it went wrong. It’s important to review all the facts:
- Interview the patient again (ask lots of questions and provide plenty of uninterrupted time to listen).
- Scrutinize test results.
- Step away from the first bits of data that led to the initial diagnosis.
- Look for the pieces of the puzzle that don’t fit.
- Be aware of how emotional reactions to a patient may influence clinical decision-making.
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