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OPHTHALMOLOGY BUSINESS 102 February 2017 by Liz Hillman EyeWorld Staff Writer visual impairment (21), followed by unnecessary procedure performed (11), blindness in both eyes (6), retinal detachments and defects (5), and polyarteritis nodosa and allied conditions (5). Unlike procedural errors where it might be easier to determine what went wrong, the map of diagnos- tic error is more complicated, said P. Divya Parikh, vice president of research and risk management for PIAA, Rockville, Maryland. Lack of medical knowledge is generally not the primary cause of diagnostic error. First impression type biases, failure to synthesize diagnostic data from multiple sources (i.e., the EHR, physical examination, diagnostic tests), failure to follow up, system-re- lated errors, communication issues, and human errors (such as physician stress or fatigue) can all play a role in diagnostic error. As for payout amount, factors including severity of the injury and jurisdiction of where the case was brought come into play. Was it an emotional injury or a grave injury that will last a lifetime, or did death occur? These influence the payout in a diagnostic error case, Ms. Parikh said. Preventing diagnostic errors Of course, no physician sets out to have a bad outcome or diagnostic error, but there are a few measures doctors and health care staff can take to prevent missed diagnosis or diagnostic error. Putting a mechanism in place to ensure all test results are received and reviewed by the doctor is im- portant because such results can get lost, resulting in a delayed or missed diagnosis, according to Dr. Custer. Another thing he recommended for his colleagues is to understand the different biases that can come into play with clinical reasoning and decision making. "A common one is anchoring bias, where you're unable to break away from the initial impression and have difficulty considering an alternative diagnosis. Cognitive forc- ing functions can help physicians minimize the effects of the different biases," Dr. Custer said. "One tech- nique to use when meeting complex patients is to look at them with a fresh set of eyes: If you hadn't heard the previous diagnosis, what would specifically related to this specialty. Of those, 14% of claims were diag- nostic error, while improper perfor- mance in surgery comprised more than half. "If we look at indemnity paid, the diagnostic area actually increas- es," Dr. Abbott said. "There is more financial reward given to patients where there is diagnostic error. … If you look at the top 10 largest claims from OMIC over the past several years, almost all of them deal with missed diagnosis or diagnostic errors." The Physician Insurers Asso- ciation of America (PIAA) culled through its 32-year-old database on medical professional liability claims for EyeWorld. It found in the last 10 years, ophthalmology had 2,325 closed claims, 564 of which were paid. The top medical factors for paid claims in ophthalmology were improper performance (274 paid claims) and error in diagno- sis (86 paid claims), 27% vs. 41%, respectively. The average indemnity payout for diagnostic error was more than $336,000 compared to more than $265,000 for improper perfor- mance. The top issues in ophthalmol- ogy that resulted in paid claims for diagnostic error included those that resulted in moderate to severe much is when you go to the doctor and are being treated for a condi- tion, and then later it turns out the diagnosis was incorrect and the treatment inappropriate." The challenge is distinguishing when a misdiagnosis or diagnos- tic error is actually subpar care. The Institute of Medicine defines diagnostic error as the "failure to (a) establish an accurate and timely explanation of the patient's health problem(s) or (b) communicate that explanation to the patient." 1 Diagnostic error in ophthalmology From an overall standpoint, the Institute of Medicine's committee that studied diagnostic error in the 2015 report "Improving diagnosis in health care" concluded "most people will experience at least one diagnostic error in their lifetime, sometimes with devastating con- sequences." Richard Abbott, MD, clinical professor of ophthalmol- ogy, University of California, San Francisco, said at the 2016 American Academy of Ophthalmology annual meeting that the Ophthalmic Mu- tual Insurance Company (OMIC), which insures about 4,600 ophthal- mologists, has about 4,000 closed claims and lawsuits in its database Though less frequent than improperly performed procedures, payouts for diagnostic error claims are higher W hen it comes to medi- cal professional liabil- ity claims, diagnostic error is considered rar- er compared to claims stemming from alleged improperly performed procedures. However, data shows that when diagnostic error claims result in indemnity paid, they are usually higher than the latter cause. "It's a major issue if you look at dollars spent," said Philip Custer, MD, professor of ophthalmology and visual sciences, Washington University School of Medicine, St. Louis. "I think public perception is that medicine is an exact science and in this day and age we should be able to be secure in a diagnosis. Patients are probably less under- standing that diagnostic error is a possibility. … Let's say someone has an untoward event during a pro- cedure; we all know that when we go into surgery the unexpected can happen, that it's at least a possibility. Where you don't expect it quite as Diagnostic error presents "major issue" in liability claims

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