Patient Safety Topics
:
Diagnostic Improvement
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

Key Data and Statistics

A query of the Pennsylvania Patient Safety Reporting System database for Serious Events likely to involve diagnostic error or the diagnostic process reported during calendar year 2016 yielded 1,212 event reports, from which the Authority identified 138 diagnostic process failure events. The Authority modified the diagnostic error evaluation and research (DEER) taxonomy and classified events according to process step and failure point. In the event reports, failure points in testing were involved most frequently (68.1%, n = 94 of 138) and the surgical/procedural care area predominated (21.0%, n = 29 of 138). Although the monitoring/follow-up process step accounted for just 13.0% of all events, it represented nearly half of those that resulted in death.

Figure 1. Percentage of Diagnostic Process Failure Events by Process Step (N =138) 

Table 2. PA-PSRS Event Narrative Examples

  

Excerpted from: Jones R, Magee MC. Identifying and learning from events involving diagnostic error: it’s a process . Pa Patient Saf Advis 2018 Oct 31 [cited 2018 Oct 31]. http://patientsafety.pa.gov/ADVISORIES/Pages/201810_IdentifyingandLearning.aspx.

Educational Tools

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

Patient Diagnostic Process - Patient
​​
​​A poster geared towards patients being an active part of their diagnosis.
 
A poster geared towards healthcare workers and the diagnostic process.
Multimedia

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

https://jdc.jefferson.edu/hpforum/125/

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

https://www.youtube.com/watch?v=tYRd8xbFQxQ

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

https://www.youtube.com/watch?v=cxTv-JuhF0s&list=PLQ8bRZ9aQtty53wZSw9ET-sn4Z-KejsA6

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.  

 

Articles

 

 

Safety Tips for Patients

 

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