Many personal and philosophical reasons make it hard to learn from diagnostic safety events. Clinicians endure years of training in medical sciences followed by arduous years of apprenticeship training. Their deep foundation of knowledge and clinical reasoning skills are gained at a great price (financial and personal) and is highly treasured. Questions about diagnostic errors challenge their sense of competency and can undermine confidence.
The reaction to questions about diagnostic safety events may range from denial to shame. The requirement to subject one’s care to examination is threatening. In fact, most physicians do not participate in reporting mechanisms, perhaps out of unwillingness to confront error. It is also possible that they value other activities, have other pressing priorities with their clinical time, or may find little value from the exercise.9,10
The ever-present threat of malpractice suits also chills open and frank discussions around quality of care. One strategy is to frame discussions around improvement opportunities to avoid the harsh judgment assigned to the characterization of a diagnostic safety event as an “error.”
Some may not trust independent assessments of diagnostic quality that might be viewed as capricious or unfair. The conclusion that an error happened at all might depend on the reviewer’s perspective; in fact, consensus is often difficult to achieve among peer reviewers. One can argue that reviewers should not be selected for their content expertise but rather for experience with the context and setting specific to the case for review. For example, specialists might not understand the practice setting faced by generalists, and physicians might not understand or fairly assess nurses and vice versa.
Since the cognitive component of diagnostic reasoning is often invisible or intangible, some may ask whether cognition can fairly be assessed at all without recall bias, hindsight bias, and outcome bias.11 In addition to bias, undifferentiated illness is complex and has some degree of irreducible uncertainty. Thus, attempts to characterize diagnostic reasoning as good or bad require judgment that may not be objective or easily standardized.11
Organizational barriers also limit examination of diagnostic events. In general, most clinicians receive little feedback from other providers or from different care settings, so many diagnostic errors are never recognized.12,13 When they are, the lack of standards and benchmarks for diagnostic quality make it difficult to make fair and objective (unbiased) assessments.14
In some settings, the complex sociotechnical system approach to understanding diagnosis may not be appreciated, and reviews by existing quality personnel may not fully investigate system contributions to diagnostic problems.15 In addition, organizations may not support adequate infrastructure to facilitate reporting. The lack of informatics support designed to capture data on diagnostic quality impedes routine assessment of diagnostic performance.
These challenges and barriers, however daunting, still have potential solutions that can be achieved given a safe and supportive environment open to learning and improvement.
