Diagnostic safety can be significantly improved by addressing the systems-based issues and cognitive factors that can lead to diagnostic errors.
Patient safety is the cornerstone of high-quality health care. Much of the work defining patient safety and practices that prevent harm have focused on negative outcome of care, such as falls, wrong-site surgery, post-surgical complications, nosocomial infections , medication errors, etc. which may lead to increased morbidity and mortality. Relative to these issues, matters related to patient safety in diagnosis have represented a blind spot in health care, even though failures in the timely and correct diagnosis can have serious consequences for patients and their families. Although it is a complex, largely cognitive process that solely contributes substantially in identifying a patient’s health problem, the role of diagnosis is undervalued as it is more difficult to evaluate and measure than other parts of the patient safety agenda.
A diagnostic error is the failure to establish a correct and timely explanation of a patient’s health problem, which can include delayed, incorrect, or missed diagnosis, or a failure to communicate that explanation to the patient. We must acknowledge that to initiate appropriate treatment and optimize the patient outcome, diagnosing the diagnostic errors and its prevention is the matter of utmost importance. Because diagnosis is a process, it is important to note that not all changes in diagnosis are synonymous with error. Establishing the correct diagnosis may take time due to insufficient diagnostic information, atypical presentation or clinical evolution. A lengthy diagnostic process can be without error but any gaps that arise in the diagnostic process can lead to error. In healthcare today, diagnostic error has been increasingly recognized as threat that can inflict no harm to significant harm to the patients, including prolonged illness and death, accounting for 6-17 percent of preventable adverse events worldwide. With most adults likely to face at least one diagnostic error in their lifetime, substantial work needs to be done to improve the safety of diagnostic processes.
To reach a diagnosis, patients and their health care teams must work together to navigate the complex and sometimes lengthy diagnostic process. Patient safety is often compromised by the downstream consequences of erroneous, untimely and miscommunicated diagnoses and errors in the use and performance of diagnostic tests. An incorrect/missed or delayed diagnosis can result in the patient not receiving the necessary medical care, unnecessary treatment which poses significant health risks. Systemic factors that predispose to diagnostic errors are organizational vulnerabilities, including communication failures between health workers or health workers and patients, heavy workloads, and ineffective teamwork. Cognitive factors involve clinician training and experience as well as predisposition to biases, fatigue and stress.
Diagnostic safety henceforth plays a crucial role in patient safety. This helps to treat serious health problems at an early stage, which improves the chances of recovery and can reduce healthcare costs. It also helps to use resources more efficiently. Medical resources such as time, personnel, equipment and financial resources can be used more effectively when the diagnosis is certain and accurate.
In addition, a reliable diagnosis helps maintain patients' trust in the healthcare system and healthcare professionals. Furthermore, when patients understand that their diagnosis is correct, they are more willing to actively participate in their own healthcare. This includes adhering to treatment plans, implementing lifestyle changes and collaborating with the treatment team. Overall, a secure diagnosis goes a long way in ensuring that patients receive the best possible care and treatment, which ultimately improves their safety and well-being.
Taking into consideration the diagnostic safety issues, the global patient safety action plan 2021-2030 highlighted the need for ensuring the safety of diagnostic processes, encouraging countries to adopt strategies that reduce diagnostic errors, which often arise from a combination of cognitive and system factors that impact the recognition of patients’ key signs and symptoms, and the interpretation and communication of their test results.
World Patient Safety Day, one of WHO’s global public health days, observed annually on 17 September, is the cornerstone of action to promote global health and safety. It’s objectives are to increase public awareness and foster collaboration between patients, health workers, policymakers and health care leaders, enhance global understanding and work towards global solidarity to promote patient safety. Each year, a new theme is selected to celebrate this day to highlight a priority patient safety area needing urgent and concerted action. Recognizing the critical importance of correct and timely diagnoses in ensuring patient safety and improving health outcomes, “Improving diagnosis for patient safety” with the slogan “Get it right, make it safe!” has been selected as the theme for World Patient Safety Day 2024.
Through the slogan “Get it right, make it safe!”, WHO calls for concerted efforts to significantly reduce diagnostic errors through multifaceted interventions rooted in systems thinking, human factors and active engagement of patients and families, health workers, healthcare leaders, policy makers and civil society will emphasize the pivotal role of correct and timely diagnosis in improving patient safety. These interventions include but are not limited to ascertaining complete patient history, undertaking thorough clinical examination, improving access to diagnostic tests, implementing methods to measure and learn from diagnostic errors, and adopting technology-based solutions.
Objectives of World Patient Safety Day 2024
1. Raise global awareness of errors in diagnosis contributing to patient harm and emphasize the pivotal role of correct, timely and safe diagnosis in improving patient safety.
2. Give prominence to diagnostic safety in patient safety policy and clinical practice at all levels of health care, aligned with the Global Patient Safety Action Plan 2021–2030.
3. Foster collaboration among policy-makers, health care leaders, health workers, patient organizations, and other stakeholders in advancing correct, timely and safe diagnosis.
4. Empower patients and families to actively engage with health workers and health care leaders to improve diagnostic processes.
With the rest of the world, several healthcare sectors in Guwahati have led the charge for ensuring patient safety and quality of care by establishing a highly reliable and resilient system for accurate diagnosis of any disease in the shortest possible time, incorporating patient safety and quality programs, getting accreditation from various boards like NABH, ISO & NABL etc. Health-related sectors in Guwahati are gearing up to celebrate World Patient Safety Day 2024 with a wide range of activities, such as workshops, social media activities, poster display, technical events, which will be organized on and around 17 September.
World Patient Safety Day, 17 September 2024: “Improving diagnosis for patient safety”
"Get it right, make it safe!"
World Patient Safety Day is an opportunity to raise public awareness and foster collaboration between patients, health workers, policymakers and health care leaders to improve patient safety.
This year the theme is “Improving diagnosis for patient safety” with the slogan “Get it right, make it safe!”, highlighting the critical importance of correct and timely diagnosis in ensuring patient safety and improving health outcomes.
Source: WHO
(The author is a practicing medical professional. All thoughts expressed are her own.)