The central cause of avoidable harm to patients in hospitals, in a senior UK doctor's opinion, is diagnostic error.
Gordon Caldwell, a consultant physician at Worthing Hospital in Western Sussex, argued that doctors need better facilities and sufficient time to make a correct diagnosis.
When a patient is admitted to hospital, the team of doctors formulate a "working diagnosis," he explained.
At this point, the diagnosis is uncertain but the patient is treated as if the working diagnosis is correct.
"If over the next few days the patient gets better, the working diagnosis is confirmed and becomes the diagnosis," he said.
However, if the patient does not improve, "we think again and consider whether the working diagnosis was wrong."
He warned: "The time taken to reach the correct diagnosis may critically impact on the patient's chances of survival. Over my career, I have seen many errors in the working diagnosis causing harm and even death to patients."
Little consideration seems to have been given to how doctors make and refine the working diagnosis and treatment plan for the patient, he adds. "We must allow clinicians enough time to be careful in diagnosis, treatment planning and treatment review."