Diagnostic error

In 2015, the National Academy of Medicine published the report ‘Improving Diagnosis in Health Care’, presenting diagnostic errors as a major challenge to patient safety.6 Leape et al found that 8% of disabling injuries in the hospital stem from diagnostic mishaps (improper or delayed diagnosis), showing this type of adverse event being associated with the highest rate of severe disability.7 Shojania et al later suggested that up to one in ten deaths in US hospitals annually involve clinically undetected major diagnoses,8 and Newman-Toker et al recently estimated that 795 000 Americans become permanently disabled or die annually because dangerous diseases are misdiagnosed.9

Diagnostic error information can come from autopsy data, normal communication in healthcare organisations, peer review and adverse event reporting.7 8 Patient complaints related to diagnostic errors can be an additional source of data. Diagnostic errors are frequent in patient complaints10 11 and constitute a leading type of paid medical malpractice claims.6

In order to use diagnostic errors from complaints, a procedure should be used that ensures systematic analysis and enables data aggregation. Using a validated tool can help ensure that, when analysing diagnostic errors in complaints, attention is not on cases that attract more attention (public or internal) and that focus is on systems rather than on individuals. Systematic approaches using, for example, HCAT, may help ensure unbiased handling of diagnostic errors reported in patient complaints and inform initiatives to improve patient safety.

Using tools to systematically analyse complaints for diagnostic errors can lead to actions such as training in diagnostic skills, simulation and artificial intelligence to support diagnosis.6 Diagnostic errors may, however, also be related to challenges at other levels of healthcare delivery, including problems at the organisational level or with communicating with patients.

Management problems and institutional processes

Problems with access to care can lead to crowding, delayed diagnosis and harm.12 In parallel, patient complaints often refer to these access problems.11 In this regard, studies have suggested that particular process improvement techniques aiming at decreasing emergency department waiting times while upholding healthcare quality may be effective.13 Complaints may pinpoint the access issue from the patient’s perspective and thereby can help focus process improvement programmes.10

Communication

The role of communication deficits as an important contributing factor in many complaints has been repeatedly stressed in the literature. For example, early studies by Beckman et al suggested that the decision to initiate malpractice litigation is often associated with poor information delivery and lack of collaboration with patients in healthcare.14 Likewise, later studies have underscored the significance of poor communication in patient complaints.15 Well-established approaches are available for training healthcare professionals’ skills for communicating with patients,16 and it could be tempting to seek to upgrade healthcare professionals’ communication skills more generally. Complaints, however, relate differently to communication problems in different healthcare areas.10 11 Systematic complaint analyses may help point to exactly where in healthcare provision and in what way communication issues are the most prominent element. Moreover, analyses can deepen our understanding of the effects of miscommunication, like, for example, deficient listening to patients’ symptoms and worries eventually leading to diagnostic errors.

Integrating the patient perspective in quality improvement through systematic use of data from patient complaints

Tools such as the HCAT can help find quality issues from patient complaints.10 We are now going to start to integrate the complaint analyses into improvement initiatives and study the results. The previously discussed examples require systematic complaint analysis to drive improvements and prevent blame on individuals. Otherwise, this important source of patient-driven data will remain largely unused, and the individual-blaming potential of complaints may dominate. Furthermore, healthcare organisations need to consider complaint data on equal terms with other data sources (hospital performance measures, readmission rates, adverse event reports, etc) and acknowledge the unique perspective of healthcare users on problems in healthcare provision. Finally, organisations must systematically integrate learning from complaints into clinical practice through well-established improvement models. It is no pity to receive a well-founded complaint about healthcare. However, it is a pity to draw no learning from it!