Négliger les erreurs de diagnostic : les graves conséquences potentielles pour la sécurité des patients
Pourquoi c'est important
« Selon les analyses menées par la Société danoise pour la sécurité des patients, les erreurs de diagnostic sont non seulement courantes, mais elles ont également des conséquences majeures pour les patients et les finances du système de santé. »
Photo de Dmitriy Gutarev | Pixabay
Au niveau international, on assiste à une prise de conscience croissante du fait que les erreurs de diagnostic constituent un problème majeur, trop souvent négligé, en matière de sécurité des patients. Selon les analyses menées par la Société danoise pour la sécurité des patients, les erreurs de diagnostic sont non seulement courantes, mais elles ont également des conséquences majeures pour les patients et les finances du système de santé. Nous espérons que la sensibilisation au processus de diagnostic et aux vulnérabilités possibles contribuera à améliorer la sécurité des patients.
Commençons par définir la portée de notre analyse. Pour mieux comprendre le processus et son potentiel de préjudice, nous avons examiné les diagnostics tout au long du parcours du patient. La première étape consiste à obtenir l'accès au système de soins de santé. L'évaluation diagnostique initiale comprend ensuite l'anamnèse du patient, l'examen physique, l'évaluation de la plainte principale et des symptômes du patient, l'établissement d'un diagnostic différentiel et la prescription de tests diagnostiques. Dans la phase de test, il y a la réalisation des tests, l'interprétation des résultats et la communication des résultats. Le cas échéant, il y a ensuite le suivi médical, les orientations, les consultations et autres communications entre les professionnels de la santé, puis le suivi ultérieur entre le patient et le système de soins de santé.
Pour que les patients reçoivent le traitement et les soins appropriés dans le système de santé, un diagnostic rapide et correct est une condition préalable. Un diagnostic négligé, tardif ou incorrect peut avoir de graves conséquences pour les patients et leurs familles. Dans le pire des cas, cela peut inclure une incapacité de travail, une déficience ou le décès. Par conséquent, l'amélioration de la sécurité et de la fiabilité du processus de diagnostic présente de grands avantages potentiels aux niveaux individuel, social, sociétal et économique.
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Au Danemark, au lieu de devoir saisir la justice pour obtenir réparation d’un préjudice subi dans le système de santé, les patients peuvent s’adresser gratuitement à une autorité publique pour obtenir réparation. En 2019, la Société danoise pour la sécurité des patients et l’Association danoise d’indemnisation des patients (dont le but est d’évaluer les demandes d’indemnisation conformément à la loi danoise sur l’indemnisation des patients) ont publié le rapport « Améliorer le diagnostic dans les soins de santé danois », qui a révélé la fréquence élevée des erreurs de diagnostic au Danemark. Le rapport a révélé qu’au cours de la période de 10 ans entre 2009 et 2018, 2,25 milliards de couronnes danoises (environ 318 millions de dollars américains) ont été versées en indemnisation aux patients blessés en raison d’erreurs de diagnostic dans le système de santé danois.
La population du Danemark est d'environ 5,8 millions de personnes. Au cours de cette période de 10 ans, l'Association danoise d'indemnisation des patients a réglé un total de 13 000 cas impliquant une erreur de diagnostic, dont 7 600 ont été reconnus. Il s'agit de cas graves. Les décès dus à une erreur de diagnostic sont presque deux fois plus fréquents pour les erreurs de diagnostic que pour d'autres blessures médicales reconnues. Plus de 8 % des cas reconnus d'erreurs de diagnostic ont entraîné directement le décès du patient. Nous avons sélectionné 213 cas pour une analyse plus approfondie. Dans 80 % des cas analysés, un facteur contributif à l'erreur de diagnostic a pu être trouvé lors de l'évaluation clinique initiale.
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(Source : Société danoise pour la sécurité des patients) Un outil d'analyse qualitative permettant d'identifier la phase du processus de diagnostic au cours de laquelle des erreurs se sont produites a été adapté à partir d'un outil du rapport annuel d'analyse comparative 2014 du CRICO : Risques de faute professionnelle dans le processus de diagnostic .
Les données de l’Association danoise d’indemnisation des patients ne reflètent pas toutes les erreurs de diagnostic au Danemark, et il est raisonnable de supposer que les erreurs de diagnostic sont sous-déclarées car toutes les personnes ayant subi une blessure indemnisable ne déposent pas de réclamation. Les conclusions du premier rapport nous ont donné envie d’en savoir plus. En juin 2023, nous avons publié une nouvelle analyse – cette fois sur les événements indésirables – pour déterminer si ce type de cas peut aider à identifier les faiblesses du processus de diagnostic.
L'Autorité danoise de sécurité des patients collecte chaque année plus de 200 000 signalements d'événements liés à la sécurité des patients par des professionnels de santé et des patients, par le biais d'un système de signalement obligatoire et non punitif. Les signalements sont enregistrés dans la base de données danoise sur la sécurité des patients. Cette base de données n'indique toutefois pas si un événement indésirable est lié au diagnostic. Chaque cas a été évalué pour déterminer s'il était lié au processus de diagnostic.
Nous avons examiné trois échantillons différents d’événements indésirables. Un échantillon comprenait uniquement des événements graves et mortels et deux échantillons comprenaient tous les degrés de gravité, depuis l’absence de préjudice jusqu’à la gravité légère, modérée, grave et mortelle. Nous avons constaté qu’environ un tiers de tous les événements graves et mortels signalés étaient liés au processus de diagnostic. De plus, nous avons déterminé qu’il y avait au moins autant d’événements liés au diagnostic que d’événements liés aux médicaments parmi les événements graves et mortels. Comme nous l’avons constaté lors de la recherche pour notre premier rapport, notre analyse a de nouveau indiqué que, dans les événements graves et mortels liés au diagnostic, des erreurs se produisaient souvent lors de l’évaluation clinique du patient.
En examinant des échantillons présentant tous les degrés de préjudice (y compris de nombreux cas de préjudice léger ou nul), nous avons pu identifier d’autres faiblesses dans le processus de diagnostic. De nombreux événements étaient liés, par exemple, à la logistique, à la communication et au manque de suivi des résultats des tests et d’orientation.
La Société danoise pour la sécurité des patients a mis en place un réseau national pour lutter contre les erreurs de diagnostic et sensibiliser les citoyens à cette question importante de la sécurité des patients. Il ne fait aucun doute que cette question mérite une plus grande attention et une collecte de données plus systématique, au bénéfice des patients, de leurs proches, des professionnels de santé et des finances du système de santé.
Charlotte Frendved est conseillère en communication pour la Société danoise pour la sécurité des patients. Siri Tribler, MD, PhD, est consultante pour la Société danoise pour la sécurité des patients.
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Résumé en français : Améliorer le diagnostic dans les soins de santé au Danemark 2 (2023)
Résumé en français : Améliorer les diagnostics dans les soins de santé au Danemark (2019)