Course excerpt from Preventing Medical Errors in Behavioral Health
According to the World Health Organization (WHO, 2023), diagnostic errors occur in 5 to 20% of physician-patient encounters.
The National Academy of Medicine defines a diagnostic error as “the failure to establish an accurate and timely explanation of a patient’s health problems or to communicate that explanation to the patient,” therefore, delayed or missed diagnoses are considered errors as well. According to the Joint Commission, diagnostic errors result in the death or injury of 40,000 to 80,000 patients annually. Diagnostic errors are most common in primary care solo practices due to workload, time constraints, and the inability to confer easily with colleagues. Malignancies, surgical complications, and neurological, cardiac, and urological issues are the 5 conditions most frequently misdiagnosed. According to studies, these conditions are frequently misdiagnosed secondary to knowledge gaps, resulting in deficient bedside assessment and clinical reasoning. Identifying these commonly misdiagnosed conditions is beneficial, as diagnostic errors are primarily cognitive rather than organization-based errors; therefore, clinicians can be forewarned of the potential challenges when caring for these patients. In addition to a clinical knowledge deficiency, common contributing factors to diagnostic error include a clinician’s fatigue, distraction, failure to consider differential diagnoses, neglect of diagnostic testing follow-up, and inadequate patient follow-up care. (Singh et al., 2024, para. 36)
Clearly, the failure to arrive at an accurate diagnosis – or diagnoses, in many cases – can be a leading cause of error in behavioral health care. According to the preface of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition Text Revision (DSM-5 TR), (American Psychiatric Association, 2022), the DSM has been revised regularly over the past 60 years in order to “facilitate more reliable diagnoses” of mental disorders, and yet “a complete description of the underlying pathological processes is not possible for most mental disorders” (p. xxiii).
While DSM-5 TR is the latest effort on the part of the American Psychiatric Association, using it is not a simple matter. The introductory section of DSM-5 TR goes on to state:
Clinical training and experience are needed to use DSM for determining a clinical diagnosis. The diagnostic criteria identify symptoms and signs comprising affects, behaviors, cognitive functions, and personality traits, along with physical signs, symptom combinations (syndromes), and durations that require clinical expertise to differentiate from normal life variation and transient responses to stress. (p. 5)
To make matters even more complex, even for those clinically trained, DSM-5 TR recognizes that “mental disorders do not always fit completely within the boundaries of a single disorder. In recognition of this reality, the disorders included in DSM-5 were reordered” (p. xxiii).
By reordering and regrouping the existing disorders, the revised structure is meant to stimulate new clinical perspectives and to encourage researchers to identify the psychological and physiological cross-cutting factors that are not bound by strict categorical designations (p. 12).
Changes to Categorical Designations
One example of this is the DSM-5 TR category autism spectrum disorder, formerly split into the DSM-IV categories of autistic disorder, Asperger’s disorder, and pervasive developmental disorder not otherwise specified. DSM-5 TR instructs that individuals formerly diagnosed with one of those DSM-IV categories should now be given the diagnosis of autism spectrum disorder. A distinct diagnosis of Social (Pragmatic) Communication Disorder is appropriate for individuals with deficits that “are not better explained by low abilities in the domains of structural language or cognitive ability or by autism spectrum disorder” (American Psychiatric Association, 2022, p. 54).
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