Diagnostic Error | Patient Safety Topic

Patient Safety Topics

Diagnostic Improvement

Overview Articles Educational Tools Multimedia Related Links Safety Tips for Patients

Overview

According to the National Academy of Medicine, most people will experience at least one diagnostic error in their lifetime, sometimes with fatal outcomes. The toll of diagnostic error in the United States is estimated at 40,000 to 80,000 deaths a year.

Through its Center of Excellence, the Authority provides leadership, guidance, and support for health care facilities and systems, providers, patients, and all interested stakeholders to improve diagnosis throughout the Commonwealth.

The Center of Excellence focuses on the following key objectives while working toward its vision of accurate and timely diagnoses communicated to all patients:

Gathering, synthesizing, and sharing information to broaden awareness and knowledge about this complex topic
Building partnerships and creating new networks between organizations to accelerate and scale improvements
Facilitating the development and implementation of novel solutions and inspiring healthcare providers and patients to work together to strengthen the diagnostic process

Educational Tools

Modified DEER Taxonomy
This adapted taxonomy may be used to classify where a failure occurred during the diagnostic process.

Diagnostic Process – Patient
A poster geared towards patients being an active part of their diagnosis.

Diagnostic Process- Healthcare Workers

A poster geared towards healthcare workers and the diagnostic process.

Multimedia

Influencing a Culture of Learning from Diagnostic Errors at a Health System

At Geisinger, the multidisciplinary Committee to Improve Clinical Diagnosis and the Safer Dx Learning Lab (a collaboration with Baylor College of Medicine) are taking a systematic approach to learn how health care systems can enhance the safety and accuracy of the diagnostic process. Join Divvy Upadhyay, MD, MPH, program lead and scientist in the division of quality, safety, and patient experience at Geisinger, to understand how this “learning health system” approach is being implemented to improve diagnostic safety across the health system.

A Cognitive Bias Think Tank: Thinking, Talking, Making a Change

The Children’s Hospital of Philadelphia (CHOP) has been on journey to overcome the cognitive biases that may contribute to diagnostic error. Join Ursula Nawab, MD, Avram H. Mack, MD, and Andrea Colfer, MSN, as they discuss various aspects of CHOP’s Cognitive Bias Think Tank, including its history and formation, current objectives, quality improvement initiatives, and next steps to inform future work.

Diagnostic Error: A Patient Safety Imperative: Featuring Becky Jones and Dr. Tim Mosher

Diagnostic errors are a complex and often overlooked problem in the field of patient safety. While various cognitive and system factors contribute to the problem, there are many opportunities for improvement.

Reducing Harm by Getting Patients the Right Diagnosis at the Right Time: Featuring Paul Epner, Dr. David Newman-Toker and Dana Siegal

Diagnostic errors are the most common, catastrophic and costly of all medical errors—resulting in thousands of patients suffering serious harm every year. The healthcare community is beginning to understand where and when they happen most frequently, and with the highest severity. It is time to take steps to prevent misdiagnoses and ensure patients get the right diagnosis at the right time.

Addressing Diagnostic Error: Featuring Dr. Mark Graber

Discussed are the likelihood of diagnostic error in physician practices, the most common system-related and cognitive causes of diagnostic error, and interventions to reduce the risk of harm from diagnostic error.

In the spring of 2018, the Authority convened an expert panel of 10 speakers to discuss issues in diagnostic error and strategies for improvement.

Related Links

Improving Diagnosis in Health Care

Getting the right diagnosis is a key aspect of health care: it provides an explanation of a patient's health problem and informs subsequent health care decisions. The diagnostic process is a complex, collaborative activity that involves clinical reasoning and information gathering to determine a patient's health problem. Diagnostic errors may cause harm to patients by preventing or delaying appropriate treatment, providing unnecessary or harmful treatment, or resulting in psychological or financial repercussions. National Academies of Sciences, Engineering, and Medicine. 2015. Improving Diagnosis in Health Care. Washington, DC: The National Academies Press. https://doi.org/10.17226/21794.

Recommendations for Improving Diagnosis in Health Care—Institute of Medicine

The Institute of Medicine provides eight goals to improve diagnosis in healthcare including facilitating more effective teamwork among health care professionals, patients, and their families; and enhancing health care professional education and training in the diagnostic process.

Improving Diagnostic Quality & Safety/Reducing Diagnostic Error: Measurement Considerations

The Diagnostic Process and Outcomes domain of the Framework addresses the actions and processes that are carried out by healthcare providers and/or teams to develop, refine, and confirm a diagnosis, or to explain the patient's health problem. The updated environmental scan identified several articles that add additional breadth to some subdomains, describing additional interventions and approaches that may be useful in reducing diagnostic error.

Serious misdiagnosis-related harms in malpractice claims: The "Big Three"—vascular events, infections, and cancers

The "Big Three" diseases—vascular events, infections, and cancers—account for about three-fourths of serious misdiagnosis-related harms. Initial efforts to improve diagnosis should focus on vascular events, infections, and cancers.

The new diagnostic team. 2017.
This article discusses an expanded diagnostic team—including nurses and allied health professionals, as well as the patient—that supports the diagnostic process.

Patient involvement strategies for diagnostic error mitigation. 2013.
This article contains a list of patient tactics for preventing and detecting diagnostic errors, including telling your story well, being an informed patient, and ensuring follow-up on testing. The authors encourage patients to report diagnostic error.

Defining the role of nurses in diagnostic error prevention. 2017

Patient's toolkit for diagnosis. 2015.
This toolkit helps patients prepare for a visit with their healthcare provider by providing a format with prompts for telling their story clearly.

Beyond the lab: the link between health IT and laboratory testing. 2018.
This article presents risk reduction strategies including assembling a multidisciplinary team to evaluate and improve the total testing process, simplifying test names in order menus, monitoring the display of results, and establishing a communication plan for incomplete specimens, cancelled specimens, and amended results.

Clinical reasoning toolkit. [accessed 2018].
This toolkit shares resources as an introduction to clinical reasoning.

Patient flow in the ED - diagnostic evaluation through disposition decision. 2015.
This article includes general principles to enhance patient safety related to the diagnostic process in the ED setting.

Patient flow in the ED - after disposition through departure. 2015.
This article includes strategies to enhance patient safety related to monitoring, communication, and a reference from the Agency for Healthcare Research and Quality on a feedback mechanism about a patient's ED diagnosis versus final diagnosis.

Articles

Safety Tips for Patients

Diagnostic Improvement: Getting the Right Diagnosis