Reducing Diagnostic Error

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.

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