Improving Diagnosis in Health Care PDF
Preview Improving Diagnosis in Health Care
THE NATIONAL ACADEMIES PRESS This PDF is available at http://nap.edu/21794 SHARE Ū ſ Ŷ Þ Improving Diagnosis in Health Care DETAILS 472 pages | 6 x 9 | PAPERBACK ISBN 978-0-309-37769-0 | DOI 10.17226/21794 CONTRIBUTORS GET THIS BOOK Erin P. Balogh, Bryan T. Miller, and John R. Ball, Editors; Committee on Diagnostic Error in Health Care; Board on Health Care Services; Institute of Medicine; National Academies of Sciences, Engineering, and Medicine FIND RELATED TITLES Visit the National Academies Press at NAP.edu and login or register to get: – Access to free PDF downloads of thousands of scientific reports – 10% off the price of print titles – Email or social media notifications of new titles related to your interests – Special offers and discounts Distribution, posting, or copying of this PDF is strictly prohibited without written permission of the National Academies Press. (Request Permission) Unless otherwise indicated, all materials in this PDF are copyrighted by the National Academy of Sciences. Copyright © National Academy of Sciences. All rights reserved. Improving Diagnosis in Health Care Committee on Diagnostic Error in Health Care Erin P. Balogh, Bryan T. Miller, and John R. Ball, Editors Board on Health Care Services Institute of Medicine Copyright National Academy of Sciences. All rights reserved. Improving Diagnosis in Health Care THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001 This activity was supported by Contracts HHSH25034020T and 200-2011-38807, TO#20 between the National Academy of Sciences and the Agency for Healthcare R esearch and Quality and the Centers for Disease Control and Prevention, re- spectively. This study was also supported by the American College of Radiology, American Society for Clinical Pathology, Cautious Patient Foundation, College of American Pathologists, The Doctors Company Foundation, Janet and Barry Lang, Kaiser Permanente National Community Beneft Fund at the East Bay Community Foundation, and Robert Wood Johnson Foundation. Any opinions, fndings, conclusions, or recommendations expressed in this publication do not necessarily refect the views of any organization or agency that provided support for the project. Library of Congress Cataloging-in-Publication Data Names: Balogh, Erin, editor. | Miller, Bryan T., editor. | Ball, John, 1944- , editor. | Institute of Medicine (U.S.). Committee on Diagnostic Error in Health Care, issuing body. Title: Improving diagnosis in health care / Committee on Diagnostic Error in Health Care ; Erin P. Balogh, Bryan T. Miller, and John R. Ball, editors ; Board on Health Care Services, Institute of Medicine, The National Academies of Sciences, Engineering, and Medicine. Description: Washington, DC : The National Academies Press, [2015] | Includes bibliographical references. Identifers: LCCN 2015041708|ISBN 9780309377690 (pbk.) | ISBN 9780309377706 (pdf) Subjects: | MESH: Diagnostic Errors—prevention & control—United States. | Diagnostic Techniques and Procedures—United States. Classifcation: LCC RC71.5 | NLM WB 141 | DDC 616.07/50289—dc23 LC record available at http://lccn.loc.gov/2015041708 Additional copies of this report are available for sale from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. Copyright 2015 by the National Academy of Sciences. All rights reserved. Printed in the United States of America Cover credit: LeAnn Locher & Associates. Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2015. Improving diagnosis in health care. Washington, DC: The National Academies Press. Copyright National Academy of Sciences. All rights reserved. Improving Diagnosis in Health Care The National Academy of Sciences was established in 1863 by an Act of Con- gress, signed by President Lincoln, as a private, nongovernmental institution to advise the nation on issues related to science and technology. Members are elected by their peers for outstanding contributions to research. Dr. Ralph J. Cicerone is president. The National Academy of Engineering was established in 1964 under the char- ter of the National Academy of Sciences to bring the practices of engineering to advising the nation. Members are elected by their peers for extraordinary contributions to engineering. Dr. C. D. Mote, Jr., is president. The National Academy of Medicine (formerly the Institute of Medicine) was estab lished in 1970 under the charter of the National Academy of Sciences to advise the nation on medical and health issues. Members are elected by their peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau is president. The three Academies work together as the National Academies of Sciences, E ngineering, and Medicine to provide independent, objective analysis and a dvice to the nation and conduct other activities to solve complex problems and inform public policy decisions. The Academies also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding in matters of science, engineering, and medicine. Learn more about the National Academies of Sciences, Engineering, and Medi- cine at www.national-academies.org. Copyright National Academy of Sciences. All rights reserved. Improving Diagnosis in Health Care Copyright National Academy of Sciences. All rights reserved. Improving Diagnosis in Health Care COMMITTEE ON DIAGNOSTIC ERROR IN HEALTH CARE JOHN R. BALL (Chair), Executive Vice President Emeritus, American College of Physicians and American Society for Clinical Pathology ELISABETH BELMONT, Corporate Counsel, MaineHealth ROBERT A. BERENSON, Institute Fellow, Urban Institute PASCALE CARAYON, Procter & Gamble Bascom Professor in Total Quality and Director, Center for Quality and Productivity Improvement, University of Wisconsin–Madison CHRISTINE K. CASSEL, President and Chief Executive Offcer, National Quality Forum CAROLYN M. CLANCY, Chief Medical Offcer, Veterans Health Administration, Department of Veterans Affairs MICHAEL B. COHEN, Medical Director, Anatomic Pathology and Oncology Division, ARUP Laboratories; Professor and Vice Chair for Faculty Development, Ombudsperson, Health Sciences Center, University of Utah School of Medicine PATRICK CROSKERRY, Professor of Emergency Medicine and Director, Critical Thinking Program, Dalhousie University Medical School, Dalhousie University THOMAS H. GALLAGHER, Professor and Associate Chair, Department of Medicine; Director, Hospital Medicine and Center for Scholarship in Patient Care Quality and Safety, University of Washington CHRISTINE A. GOESCHEL, Assistant Vice President, Quality, MedStar Health MARK L. GRABER, Senior Fellow, RTI International HEDVIG HRICAK, Chair, Department of Radiology, Memorial Sloan Kettering Cancer Center ANUPAM B. JENA, Associate Professor of Health Care Policy and Medicine, Harvard Medical School ASHISH K. JHA, K.T. Li Professor of International Health and Director, Harvard Global Health Institute, Harvard T.H. Chan School of Public Health MICHAEL LAPOSATA, Professor and Chair, Department of Pathology, University of Texas Medical Branch at Galveston KATHRYN McDONALD, Executive Director and Senior Scholar, Center for Health Policy and Center for Primary Care and Outcomes Research, Stanford University ELIZABETH A. McGLYNN, Director, Center for Effectiveness and Safety Research, Kaiser Permanente v Copyright National Academy of Sciences. All rights reserved. Improving Diagnosis in Health Care MICHELLE ROGERS, Associate Professor, College of Computing and Informatics, Drexel University URMIMALA SARKAR, Associate Professor of Medicine, University of California, San Francisco GEORGE E. THIBAULT, President, Josiah Macy Jr. Foundation JOHN B. WONG, Chief, Division of Clinical Decision Making, Tufts Medical Center Study Staff ERIN BALOGH, Study Director BRYAN MILLER, Research Associate (from August 2014) SARAH NAYLOR, Research Associate (until August 2014) KATHRYN GARNHAM ELLETT, Research Associate (from April 2015 to July 2015) CELYNNE BALATBAT, Research Assistant (until June 2015) PATRICK ROSS, Research Assistant (from April 2015) LAURA ROSEMA, Christine Mirzayan Science and Technology Policy Graduate Fellow (from January to April 2014) BEATRICE KALISCH, Nurse Scholar in Residence (until August 2014) PATRICK BURKE, Financial Associate ROGER HERDMAN, Director, Board on Health Care Services (until June 2014) SHARYL NASS, Director, Board on Health Care Services (from June 2014); Director, National Cancer Policy Forum vi Copyright National Academy of Sciences. All rights reserved. Improving Diagnosis in Health Care Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confdential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: SUZANNE BAKKEN, Columbia University DONALD BERWICK, Institute for Healthcare Improvement PAUL CHANG, University of Chicago Hospitals JAMES J. CIMINO, University of Alabama at Birmingham SARA J. CZAJA, University of Miami Miller School of Medicine GURPREET DHALIWAL, University of California, San Francisco, and San Francisco Veterans Affairs Medical Center TEJAL GANDHI, National Patient Safety Foundation HELEN HASKELL, Mothers Against Medical Error JOHN M. HICKNER, University of Illinois at Chicago MICHELLE MELLO, Stanford Law School JEFFREY MEYERS, University of Michigan MARGARET E. O’KANE, National Committee for Quality Assurance vii Copyright National Academy of Sciences. All rights reserved. Improving Diagnosis in Health Care viii REVIEWERS GORDON SCHIFF, Brigham and Women’s Hospital and Harvard Medical School SUSAN SHERIDAN, Patient-Centered Outcomes Research Institute HARDEEP SINGH, Houston Veterans Affairs Health Services Research Center for Innovations, Michael E. DeBakey Veterans Affairs Medical Center, and Baylor College of Medicine BRIAN R. SMITH, Yale University School of Medicine LAURA ZWAAN, Erasmus Medical Center Although the reviewers listed above have provided many construc- tive comments and suggestions, they were not asked to endorse the con- clusions or recommendations nor did they see the fnal draft of the report before its release. The review of this report was overseen by BRADFORD H. GRAY, Editor Emeritus, The Milbank Quarterly, Senior Fellow, Urban Institute, and KRISTINE GEBBIE, Flinders University School of Nurs- ing and Midwifery, Adelaide, South Australia. They were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all re- view comments were carefully considered. Responsibility for the fnal content of this report rests entirely with the authoring committee and the institution. Copyright National Academy of Sciences. All rights reserved. Improving Diagnosis in Health Care Acknowledgments We thank the following individuals who spoke at the committee’s meetings: Bibb Allen, American College of Radiology Leonard Berlin, Skokie Hospital, Rush Medical College, University of Illinois Barbara Brandt, National Center for Interprofessional Practice and Education, University of Minnesota David Classen, Pascal Metrics and University of Utah School of Medicine Gurpreet Dhaliwal, University of California, San Francisco, and San Francisco Veterans Affairs Medical Center Paul Epner, Society to Improve Diagnosis in Medicine Tejal Gandhi, National Patient Safety Foundation Emmy Ganos, Robert Wood Johnson Foundation David Gross, College of American Pathologists Kerm Henriksen, Agency for Healthcare Research and Quality Devery Howerton, Centers for Disease Control and Prevention Heidi Julavits, Columbia University Allen Kachalia, Brigham and Women’s Hospital, Harvard Medical School, and Harvard School of Public Health Michael Kanter, Kaiser Permanente Jerome Kassirer, Tufts University School of Medicine Steven Kroft, American Society for Clinical Pathology Michael Millenson, Cautious Patient Foundation Elizabeth Montgomery, Cautious Patient Foundation Jeffrey Myers, University of Michigan ix Copyright National Academy of Sciences. All rights reserved.
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