Unraveling Diagnostic Error: Delving Deeply to Identify Hidden Human Factors

On the day the patient had her initial chest x-ray, Radiologist B was late for a meeting with his wife and their respective attorneys to discuss separation and divorce proceedings, and he was fearful of losing custody of his three young children. He was emotionally distracted, rushed, and relying heavily on clinical heuristic skills, thus missing the x-ray finding. Psychosocial impairment, medication and alcohol abuse, and lack of collegial and supervisory support all combined to physically and emotionally degrade Radiologist B, causing him to make a terrible error. The investigation concluded that other radiologists with similar training and experience, if confronted with similar distractions, might also have erred in interpretation of the initial x-ray.

Radiologist B was most definitely responsible and thus accountable for his misinterpretation, which certainly contributed to the timing of this patient’s death and may even have caused it. The hidden human factors contributing to his performance do not remove the responsibility and accountability from his shoulders, but they do showcase how challenging and distracting those factors can be. Opportunities for learning and improvements were thus identified.

Conclusion

Everything about healthcare is complex, and if some in our industry look for simple solutions to complex problems, they, and we, will surely miss important learning opportunities—and patients will continue to suffer.

The variability in quality of root cause analyses must be systematically addressed with the focus on delving deeper to find the rootlets—the contributing factors that ultimately nurture the roots of causality, affect individual performance, and represent the real opportunities for improvements.

Healthcare leaders must understand that there are no shortcuts or heuristics to improve patient safety. Leaders must create and sustain cultures that foster cooperative and collaborative efforts toward diagnosis, and that value the importance of incident reporting and analysis. Only by engaging with clinicians and patients, both key healthcare stakeholders, can we hope to truly mitigate errors. Leaders, and their followers, must embrace transformation of the ways that healthcare can and must be provided (Leape et al., 2009; Cohen, 2014).


Daniel L. Cohen is chief medical officer at Datix, Inc.

 

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