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J Gen Fam Med. 2017 December; 18(6): 489–490.
Published online 2017 August 29. doi:  10.1002/jgf2.126
PMCID: PMC5729374

Special report of the first Australasian Diagnostic Error in Medicine Conference from 23 to 25 May, 2017

Satoshi Watanuki, MD, 1 Yuki Aoyagi, MD, MPH, MA, 2 and Kumiko Yukawa Orimoto, MD, PhD 3

We attended the first Australasian Diagnostic Error in Medicine Conference (DEM) in Melbourne from 23 to 25 May, 2017. This is a regional version of the DEM conference that has been developed in the United States since 2007. The European version of the DEM conference was previously held in Amsterdam, Holland, in 2016.

As emphasized in “To Err is Human: Building a Safer Health System” 1 published in 2000, physicians are all humans and thus make errors in medical practice regardless of the levels of medical knowledge and experience. It is important that we should not blame physicians who make errors but rather conduct root cause analyses to improve factors contributing to such errors. Dr. Mark Graber, who is a president of the DEM conference, indicated in his historical study2 that cognitive biases and system errors are the major factors in diagnostic errors. He argues that insufficient medical knowledge and skills are less common factors.

The subtitle of the first Australasian DEM conference was “Towards safer diagnosis–a team effort”. Collaboration among healthcare professionals, patients, and their families is one of the key methods to improve the diagnostic process, as indicated in the landmark report “Improving Diagnosis in Health Care3” by Institute of Medicine (IOM). In the plenary session, Mrs. Maureen Williams, a patient advocator, presented her own experience of diagnostic error from her 100 admissions for Addison's disease. In the workshop on patient engagement, we did a role‐play to learn and overcome the difficulty of communicating with the patient when doctors are influenced by different factors (emotional stress, lack of time, etc.). We learned that a patient toolkit was one of the useful resources for the swift gathering of patient information and for a better communication between patients and healthcare professionals. There was a wide variety of participants in this conference including medical educators, nurses, patients, patient advocators, and cognitive psychologists. Their diverse backgrounds made the discussions about diagnostic errors more lively and profound.

We also had a business meeting with Mr. Paul Epner (the Executive Vice President and cofounder of the Society to Improve Diagnosis in Medicine), Dr. Carmel Crock (Conventor of this Australian DEM conference), and Dr. Yasuharu Tokuda (See Figure 1) and agreed to organize the first DEM conference in Japan in the near future. We believe hosting the DEM conference in Japan is vital in promoting diagnostic error prevention initiatives in our region. We hope all the stakeholders in health care will join the DEM conference to be hosted in our country to address issues surrounding diagnostic errors.

Figure 1
Meeting Participants (from left, Yuki Aoyagi, Mr. Paul Epner, Dr. Carmel Crock, Kumiko Orimoto, Dr. Yasuharu Tokuda, and Satoshi Watanuki)


The authors have stated explicitly that there are no conflicts of interest in connection with this article.


1. Kohn LT, Corrigan JM, Donaldson MS. To err is human: building a safer health system. Institute of Medicine (US) Committee on Quality of Health Care in America. Washington (DC): National Academies Press (US); 2000. [PubMed]
2. Graber ML, Franklin N, Gordon R. Diagnostic error in internal medicine. Arch Intern Med. 2005;165:1493–9. [PubMed]
3. Balogh EP, Miller BT, Ball JR. Improving diagnosis in health care. Washington, (DC): National Academies Press (US); 2015.

Articles from Journal of General and Family Medicine are provided here courtesy of Wiley-Blackwell