Skip to main content

Currently Skimming:

9 The Path to Improve Diagnosis and Reduce Diagnostic Error
Pages 355-402

The Chapter Skim interface presents what we've algorithmically identified as the most significant single chunk of text within every page in the chapter.
Select key terms on the right to highlight them within pages of the chapter.


From page 355...
... Diagnostic errors persist throughout all settings of care, involve common and rare diseases, and continue to harm an unacceptable number of patients. Yet, diagnosis -- and, in particular, the occurrence of diagnostic errors -- is not a major focus in health care practice or research.
From page 356...
... The second conclusion is that it is very important to consider diagnosis from a patient-centered perspective, as patients bear the ultimate risk of harm from diagnostic errors. Thus, patients should be recognized as vital partners in the diagnostic process, and the health care system needs to encourage and support their engagement and to facilitate respectful learning from diagnostic errors.
From page 357...
... . Thus, many of the recommendations focus on improving diagnosis and the diagnostic process as well on the identification and mitigation of diagnostic errors.
From page 358...
... Facilitate More Effective Teamwork in the Diagnostic Process Among Health Care Professionals, Patients, and Their Families The diagnostic process is a collaborative activity. Making accurate and timely diagnoses requires teamwork among health care professionals, patients, and their family members.
From page 359...
... . Health care organizations and health care professionals have the responsibility to create environments that are receptive to and supportive of patient engagement in the diagnostic process.
From page 360...
... . Health care professionals and organizations can also involve patients and their families in organizational learning efforts aimed at analyzing the causes of diagnostic errors and identifying interventions that could improve the diagnostic process.
From page 361...
... .1 In addition, nurses are often not recognized as collaborators in the diagnostic process, despite their critical roles in ensuring proper communication and care coordination among the health care professionals and between the professionals and the patient and his or her family; monitoring the patient's condition over time to see if the patient's course of treatment aligns with the working diagnosis; and identifying and preventing potential diagnostic errors. Depending on a particular patient's needs, 1  Personal communication, M
From page 362...
... , E including clinical notes and diagnostic testing results, to fa cilitate patient engagement in the diagnostic process and patient review of health records for accuracy. •  dentify opportunities to include patients and their families I in efforts to improve the diagnostic process by learning from diagnostic errors and near misses.
From page 363...
... However, the committee highlighted several areas that are important to the diagnostic process. Opportunities to improve the content of health care professional education and training in the diagnostic process include placing a greater emphasis on teamwork and communication with patients, their families, and other health care professionals; providing more training in the ordering of diagnostic testing and in the application of these results to subsequent decision making; and offering more training in the use of health IT.
From page 364...
... . Oversight processes, such as education and training program accreditation, licensure, and certification, can help ensure that health care professionals achieve and maintain competency in the diagnostic process.
From page 365...
... , health information exchanges, laboratory and medical imaging information systems, clinical decision support, patient engagement tools, computerized provider order entry, and medical devices. When health IT tools support the diagnostic team members and tasks in the diagnostic process and reflect human-centered design principles, health IT has the potential to improve diagnosis and reduce diagnostic errors.
From page 366...
... . Because the diagnostic process occurs over time and can involve multiple health care professionals across different care settings, the free flow of information is critical.
From page 367...
... . Patient safety risks in the diagnostic process related to the use of health IT are another important concern because there is growing recognition that the use of health IT can result in adverse events (IOM, 2012; ONC, 2014)
From page 368...
... If health IT products have the potential to contribute to diagnostic errors or have other adverse effects on the diagnostic process, health IT vendors have a responsibility to communicate this information to their users in a timely manner. Goal 3: Ensure that health information technologies support pa tients and health care professionals in the diagnostic process Recommendation 3a:  Health information technology (health IT)
From page 369...
... . Very few health care organizations have focused on the identification of diagnostic errors and near misses in clinical practice (Graber et al., 2014; Kanter, 2014; Singh, 2014; Trowbridge, 2014)
From page 370...
... In addition to identifying near misses and errors, health care organizations can also benefit from evaluating factors that are contributing to improved diagnostic performance. Given the nascent field of measurement of the diagnostic process, bottom-up experimentation will be necessary to develop approaches for monitoring the diagnostic process and identifying diagnostic errors and near misses.
From page 371...
... In addition, the committee concluded that it is appropriate to have a limited number of highly qualified health care systems participate in conducting routine postmortem exams that produce research-quality information about the incidence and nature of diagnostic errors. To accomplish this, a subset of health care systems that reflect a broad array of different settings of care could receive funding to perform postmortem examinations in a representative sample of patient deaths.
From page 372...
... Methods to monitor the diagnostic process and identify diagnostic errors and near misses can be leveraged as mechanisms to provide feedback. Feedback opportunities include disseminating postmortem examination results to clinicians who were involved in the patient's care; sharing the results of patient surveys, medical record reviews, or information gained through follow-up with the health care professionals; using patient-actors or simulated care scenarios to assess and inform health care professionals' diagnostic performance; and others.
From page 373...
... There is also an opportunity to improve diagnosis by engaging health care professional societies in identifying areas within their specialties to reduce diagnostic errors and improve diagnostic performance. This can facilitate improvements in diagnosis based on intrinsic motivation and professionalism rather than other incentives or disincentives.
From page 374...
... Proven approaches should be incorporated into updates of these requirements. Recommendation 4b:  Health care organizations should: •  onitor the diagnostic process and identify, learn from, and M reduce diagnostic errors and near misses as a component of their research, quality improvement, and patient safety programs.
From page 375...
... Organizational leaders and managers can facilitate this culture and set the priorities to achieve progress in improving diagnostic performance and reducing the occurrence of diagnostic errors. Some aspects of culture in health care organizations, such as an emphasis on quality, safety, professionalism, and the intrinsic motivation of health care professionals, promote diagnostic performance.
From page 376...
... For example, improved patient access to clinical notes and diagnostic testing results is one form of error recovery; this access gives patients the opportunity to identify and correct errors in their medical records that could lead to a diagnostic error, potentially before any harm results. Thoughtful use of redundancies, such as second reviews of anatomic pathology specimens and medical images, consultations, and second opinions in challenging cases or complex care environments, is also a form of error recovery that health care organizations can consider.
From page 377...
... Other physical environment factors that are likely to influence the diagnostic process include the placement of health IT used in the diagnostic process, the presence of noise that interferes with clinical reasoning and communication among the diagnostic team, and the amount of space available for team members to complete tasks related to the diagnostic process. Health care organizations can also make concerted efforts to address diagnostic challenges related to fragmentation within the broader health care system.
From page 378...
... •  evelop and implement processes to ensure effective and D timely communication between diagnostic testing health care professionals and treating health care professionals across all health care delivery settings. Develop a Reporting Environment and Medical Liability System That Facilitates Improved Diagnosis by Learning from Diagnostic Errors and Near Misses Reporting The committee concluded that there is a need for safe places where health care organizations and professionals can share and learn from their experiences with diagnostic errors, near misses, and adverse events.
From page 379...
... . If health care organizations or health care professionals join a specific PSO, they can then voluntarily send patient safety data to the PSO for analysis and feedback on how to improve care.
From page 380...
... ; in order to promote voluntary reporting efforts, common formats for diagnostic errors and near misses are needed. AHRQ could begin with common formats for high-priority areas such as the most frequent diagnostic errors and "don't miss" health conditions that may result in significant patient harm, such as stroke, acute myocardial infarction, and pulmonary embolism.
From page 381...
... . Diagnostic errors are a leading type of malpractice claim, and these claims are more likely to be associated with patient deaths than other types of medical errors (Tehrani et al., 2013)
From page 382...
... Thus, further demonstrations of these two approaches are warranted. CRPs are principled comprehensive patient safety programs in which health care professionals and organizations openly discuss adverse outcomes with patients and proactively seek resolution while promoting patient-centeredness, learning, and quality improvement.
From page 383...
... Many of these carriers and organizations are actively exploring opportunities to improve diagnosis and reduce diagnostic errors. Given their expertise in understanding the contributors to diagnostic errors, they bring an important perspective to efforts to improve diagnosis, both those focused on individual health care professionals and those focused on the work system components that may contribute to diagnostic errors.
From page 384...
... Recommendation 6d:  Professional liability insurance carriers and captive insurers should collaborate with health care professionals on opportunities to improve diagnostic performance through edu cation, training, and practice improvement approaches and increase participation in such programs. Design a Payment and Care Delivery Environment That Supports the Diagnostic Process Fee-for-service (FFS)
From page 385...
... . Given the importance of team-based care in the diagnostic process, the lack of financial incentives in FFS payment to coordinate care can contribute to challenges in diagnosis and diagnostic errors, particularly delays in diagnosis (Allen and Thorwarth, 2014; Kroft, 2014; Miller, 2014; Rosenthal, 2014)
From page 386...
... E&M services reflect the cognitive expertise and skills that all clinicians have and use in the diagnostic process, and the distortions may be diverting attention and time from important tasks in the diagnostic process, such as performing a patient's clinical history and interview, conducting a physical exam, and thoughtful decision making in the diagnostic process. Realigning relative value fees to better compensate clinicians for the cognitive work in the diagnostic process has the potential to improve accuracy in diagnosis while reducing the incentives that drive inappropriate utilization of diagnostic testing in the diagnostic process.
From page 387...
... Assessing the impact of payment and care delivery models, including FFS, on the diagnostic process, diagnostic errors, and learning are critical areas of focus as these models are evaluated. The committee asked for input from payment and delivery experts 6  Medicare Access and CHIP Reauthorization Act of 2015.
From page 388...
... suggested that population-based payment models, including capitation and global budgets, have the greatest potential to reduce diagnostic errors. While new payment models have the potential to reduce diagnostic errors, these models may also create incentives for clinicians and health care organizations that could reduce use of appropriate testing and clinician services (e.g., specialty consultations)
From page 389...
... Provide Dedicated Funding for Research on the Diagnostic Process and Diagnostic Errors The diagnostic process and the challenge of diagnostic errors have been neglected within the national health care research agenda (Berenson et al., 2014; Wachter, 2010; Zwaan et al., 2013)
From page 390...
... However, given the consistent lack of resources for research on diagnosis and the potential for diagnostic errors to contribute significant patient harm, the committee concluded that this is necessary for broader improvements to the quality and safety of health care. In addition, improving diagnosis could also lead to potential cost savings by preventing diagnostic errors, inappropriate treatment, and related adverse events.
From page 391...
... Recommendation 8b:  The federal government should pursue and encourage opportunities for public–private partnerships among a broad range of stakeholders, such as the Patient-Centered Out comes Research Institute, foundations, the diagnostic testing and health information technology industries, health care organiza tions, and professional liability insurers to support research on the diagnostic process and diagnostic errors. REFERENCES Adler-Milstein, J
From page 392...
... Input submitted to the Committee on Diagnostic Error in Health Care, December 2, 2014, Washington, DC. Bendix, J
From page 393...
... Input submitted to the Committee on Diagnostic Error in Health Care, October 21, 2014, Washington, DC. Burwell, S
From page 394...
... 2013. Use of health information technology to reduce diagnostic error.
From page 395...
... 2005. Diagnostic errors in medicine: A case of neglect.
From page 396...
... 2014. Legal issues in diagnostic error.
From page 397...
... 2014. Diagnostic errors -- Patient safety.
From page 398...
... Input submitted to the Committee on Diagnostic Error in Health Care, October 24, 2014, Washington, DC. Patel, V., N
From page 399...
... 2014. Twenty suggestions that could improve clinical diagnosis and reduce diagnostic error.
From page 400...
... 2013. Types and origins of diagnostic errors in primary care settings.
From page 401...
... malpractice claims for diagnostic errors 1986–2010: An analysis from the National Practitioner Data Bank. BMJ Quality and Safety 22:672–680.


This material may be derived from roughly machine-read images, and so is provided only to facilitate research.
More information on Chapter Skim is available.