Ignorando erros de diagnóstico: as graves consequências potenciais para a segurança do paciente
Por que isso importa
"De acordo com análises conduzidas pela Sociedade Dinamarquesa para a Segurança do Paciente, erros de diagnóstico não são apenas comuns, mas também têm consequências importantes para os pacientes e para as finanças do sistema de saúde."
Foto de Dmitriy Gutarev | Pixabay
Internacionalmente, há uma conscientização crescente sobre erros de diagnóstico como um grande – e muitas vezes negligenciado – problema de segurança do paciente. De acordo com análises conduzidas pela Sociedade Dinamarquesa para Segurança do Paciente, erros de diagnóstico não são apenas comuns, mas também têm consequências importantes para os pacientes e as finanças do sistema de saúde. Nossa esperança é que aumentar a conscientização sobre o processo de diagnóstico e possíveis vulnerabilidades possa ajudar a melhorar a segurança do paciente.
Vamos primeiro definir o escopo da nossa análise. Para entender melhor o processo e seu potencial de dano, analisamos os diagnósticos ao longo de toda a jornada do paciente. O primeiro passo é obter acesso ao sistema de saúde. A avaliação diagnóstica inicial inclui o histórico do paciente, exame físico, avaliação da queixa principal e sintomas do paciente, formação de um diagnóstico diferencial e solicitação de testes diagnósticos. Na fase de testes, há a realização dos testes, interpretação dos resultados e comunicação dos resultados dos testes. Quando apropriado, há então acompanhamento médico, encaminhamentos, consultas e outras comunicações entre profissionais de saúde e o acompanhamento subsequente entre o paciente e o sistema de saúde.
Para que os pacientes recebam o tratamento e o cuidado corretos no sistema de saúde, o diagnóstico oportuno e correto é um pré-requisito. Um diagnóstico que é negligenciado, atrasado ou incorreto pode ter consequências sérias para os pacientes e suas famílias. Nos piores cenários, isso pode incluir incapacidade de trabalhar, deficiência ou morte. Portanto, melhorar a segurança e a confiabilidade do processo de diagnóstico tem grandes benefícios potenciais nos níveis individual, social, societal e econômico.
Saiba mais sobre Segurança do Paciente no IHI Forum
Na Dinamarca, em vez de ter que ir ao tribunal para obter indenização por ferimentos no sistema de saúde, os pacientes podem solicitar gratuitamente a uma autoridade pública para receber indenização. Em 2019, a Sociedade Dinamarquesa para Segurança do Paciente e a Associação Dinamarquesa de Compensação ao Paciente (cujo objetivo é avaliar reivindicações de indenização de acordo com a Lei Dinamarquesa de Compensação ao Paciente) publicaram o relatório “Melhorando o Diagnóstico na Assistência Médica Dinamarquesa”, que expôs a alta frequência de erros de diagnóstico ocorrendo na Dinamarca. O relatório descobriu que no período de 10 anos entre 2009 e 2018, 2,25 bilhões de DKK (aproximadamente US$ 318 milhões) foram pagos em indenização a pacientes feridos por causa de erros de diagnóstico no sistema de saúde dinamarquês.
A população da Dinamarca é de cerca de 5,8 milhões de pessoas. Neste período de 10 anos, a Associação Dinamarquesa de Compensação ao Paciente resolveu um total de 13.000 casos envolvendo um erro de diagnóstico, dos quais 7.600 foram reconhecidos. Esses são casos sérios. A morte devido a erro de diagnóstico é quase duas vezes mais comum para erro de diagnóstico do que para outras lesões de tratamento reconhecidas. Mais de 8% dos casos reconhecidos com erros de diagnóstico resultaram diretamente na morte do paciente. Selecionamos 213 casos para análise posterior. Em 80% dos casos analisados, um fator contribuinte para o erro de diagnóstico pôde ser encontrado durante a avaliação clínica inicial.
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(Fonte: Sociedade Dinamarquesa para a Segurança do Paciente) Uma ferramenta de análise qualitativa para identificar a fase do processo de diagnóstico em que ocorreram erros foi adaptada de uma ferramenta do Relatório de Benchmarking Anual de 2014 do CRICO: Riscos de negligência médica no processo de diagnóstico .
Os dados da Danish Patient Compensation Association não refletem todos os erros de diagnóstico na Dinamarca, e é razoável supor que os erros de diagnóstico são subnotificados porque nem todos com uma lesão compensável registram uma reclamação. As descobertas do primeiro relatório nos deixaram ansiosos para aprender mais. Em junho de 2023, publicamos uma nova análise — desta vez de eventos adversos — para investigar se esse tipo de caso pode ajudar a identificar fraquezas no processo de diagnóstico.
A Autoridade Dinamarquesa de Segurança do Paciente coleta anualmente mais de 200.000 relatórios de eventos de segurança do paciente por profissionais de saúde e pacientes por meio de um sistema de relatórios obrigatório e não punitivo. Os relatórios são registrados no Banco de Dados Dinamarquês de Segurança do Paciente. O banco de dados, no entanto, não indica se um evento adverso foi relacionado ao diagnóstico. Cada caso foi avaliado para determinar se estava relacionado ao processo de diagnóstico.
Examinamos três amostras diferentes de eventos adversos. Uma amostra incluiu apenas eventos graves e fatais e duas amostras incluíram todos os graus de gravidade, de nenhum dano a leve, moderado, grave e fatal. Descobrimos que aproximadamente um terço de todos os eventos graves e fatais relatados estavam relacionados ao processo de diagnóstico. Além disso, determinamos que há pelo menos tantos eventos relacionados a diagnósticos quanto a medicamentos entre os eventos graves e fatais. Como descobrimos durante a pesquisa para nosso primeiro relatório, nossa análise novamente indicou que, em eventos graves e fatais relacionados a diagnósticos, erros frequentemente ocorreram durante a avaliação clínica do paciente.
Quando olhamos para amostras com todos os graus de dano (incluindo muitas com dano leve ou nenhum), pudemos identificar outras fraquezas no processo de diagnóstico. Muitos eventos, por exemplo, relacionados à logística, comunicação e falta de acompanhamento dos resultados dos testes e encaminhamentos.
A Danish Society for Patient Safety estabeleceu agora uma rede nacional para abordar o problema do erro de diagnóstico e aumentar a conscientização sobre essa importante questão de segurança do paciente. Não há dúvida de que esse assunto merece mais atenção e coleta mais sistemática de dados para beneficiar os pacientes, seus parentes, profissionais de saúde e as finanças do sistema de saúde.
Charlotte Frendved é consultora de comunicações da Danish Society for Patient Safety. Siri Tribler, MD, PhD, é consultora da Danish Society for Patient Safety.
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