Dr. Mark Graber spoke today regarding diagnostic error and how librarians can help. Obviously, anything with the term “error” in its name is not going to be a good thing, but Dr. Graber really brought the costs of diagnostic error home with the story of Rory Staunton, a boy whose sepsis was misdiagnosed as gastroenteritis, as well as these sobering facts:
- Falls, medication errors and other patient safety issues have seen improvements in recent years; Dx errors are still largely unrecognized.
- 40,000-80,000 deaths a year may be due to Dx error, making it the 5th leading cause of death in the U.S.
- Dx error results in more malpractice costs that any other issue.
However, the presentation was not all doom and gloom, as Dr. Graber had a number of suggestions. He pointed to the fact that real change requires both system change–policies, procedures and culture–as well as cognitive change at the individual level. And there are a number of ways librarians can help:
- Participate on clinical teams and committees to reduce Dx error.
- Educate medical professionals on the difference between analytical and intuitive thinking, as well as tacit and explicit knowledge.
- Explore tools like Dxplain and Isabel.
- Consider participating in the SIDM Librarians on Call project.