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Improving Diagnostic Quality and Safety in Clinical Settings

Illinois Risk Management Services

36th Annual Risk Managers' Meeting - Going Virtual

October 2, 2020

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2020

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Vision

Creating a world where no patients are harmed by diagnostic error.

Mission

SIDM catalyzes and leads change to improve diagnosis and eliminate harm, in partnershipwith patients, their families, the healthcare community and every interested stakeholder.

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What is a Diagnostic Error? Oct

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The failure to:

(a) establish an accurate and

timely explanation of the

patient’s health problem(s)

or

(b) communicate that explanation

to the patient1

1National Academies of Sciences, Engineering, and Medicine. 2015. Improving diagnosis in health care.

Washington, DC: The National Academies Press.

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Diagnostic Failures are Frequent, Harmful and Costly

One in 20 patients in outpatient settings will experience a diagnostic error each year = 12 million

Americans each year

Patients experiencing medical errors report misdiagnosis more often than any other error

(59%)

40,000-80,000 people die each year from diagnostic failures in U.S. hospitals alone

Estimates of the costs associated with diagnostic error exceed $100 billion per year

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ECRI Named Diagnostic Error #1 in 2018-2020

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SIDM-Funded Research Highlighted the Burden O

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Research Conclusions Oct

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Most Common 34% of medical errors causing serious harms

are diagnostic

(Rank #1)

Most Catastrophic 64% of diagnostic errors lead to death or

permanent disability (Rank #1)

Most Costly 28% of total payouts for all medical

malpractice claims (Rank #1) with a median payout of $766K per high-severity case

Diagnostic error and patient safety

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Adapted from:

Battles JB, Kaplan HS, Van der Schaaf TW, Shea CE.

The attributes of medical

event-reporting systems: experience with a

prototype medical event-reporting system for

transfusion medicine.

Arch Pathol Lab Med. 1998 Mar;122(3):231-8.

Accidents

Adverse events

Near misses

Dangerous

situations

Errors

Deviations

Precursor

events

Hazards

Reason’s Swiss Cheese Model Oct

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Reason, J. Human error: models and management. BMJ. 2000 Mar 18;320(7237):768-70.Copyright ©2000 BMJ Publishing Group Ltd.

IHI Framework for Safe, Reliable, and Effective Care

Frankel A, Haraden C, Federico F, Lenoci-Edwards J. A Framework for Safe, Reliable, and Effective Care.

White Paper. Cambridge, MA: Institute for Healthcare Improvement and Safe & Reliable Healthcare; 2017.

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1National Academies of Sciences, Engineering, and Medicine. 2015. Improving diagnosis in health care. Washington,

DC: The National Academies Press.

Improving Diagnosis is Complex

• Identifying cases is difficult

Lack of problem category in reporting systems

Lack of standard operational definitions, sensitive triggers

• Understanding the problem is complicated

Nearly all diagnoses involve uncertainty and represent an evolving process; best practices on steps and timeliness are often lacking

Investigations often do not proceed holistically – cognitive vs systematic, peer review vs RCA

• Addressing the problem is hampered by lack of tools

Feedback mechanisms don’t exist

Validated measures are limited and largely process-oriented

EMR functionality does not support the diagnostic process

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Dx Quality Improvement What’s different?

The nature of the domain

Cognitive and systematic

Variability in presentation

Uncertainty

Evolving nature

Small number of solutions

Lack of objective measures

Lack of case recognition/data categorization

Non-standard problem investigation processes

Lack of guiding resources

Various RCA tools (suboptimal with regards to DX process)

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Research Spotlights Cognition

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Clinical judgment

is involved

In more than 85%

of claims

Communications

is involved

In nearly 35% of

claims

Clinical systems

are involved

In 22% of claims

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Contributing Factor Analysis Oct

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B&W Technical Services

Pantex. Causal Factors Analysis: An Approach for

Organizational Learning.

Amarillo, TX: B&W Pantex; 2008. p. 71.

Diagnostic Error Fishbone Oct

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Reilly JB, Myers JS,

Salvador D, Trowbridge

RL. Use of a novel,

modified fishbone diagram

to analyze diagnostic

errors. Diagnosis (Berl).

2014;1(2):167-171.

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Actions to reduce risk

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Hierarchy of Effective Interventions

Stronger

Architectural/physical change

Engineering control or interlock (forcing functions)

Simplification of the process

Standardization

Tangible involvement and action by leadership

Intermediate

Redundancy

Increase in staffing/decrease in workload

Eliminate/reduce distractions (sterile cockpit)

Checklist/cognitive aid

Read-back

Enhanced documentation/communication

Weaker

Double-checks

Warnings and labels

New procedure/memorandum/policy

Training

Additional study/analysisSource: Noel Eldridge, AHRQ

Diagnostic Error Change Package

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Measurement

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Evolution of Safety Oct

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Resilience Engineering Oct

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30Hollnagel E. Resilience Engineering in Practice: A Guidebook. New ed. Burlington, VT: Ashgate; 2011. p. xxxi.

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"You cannot change the human condition. But you can change

the conditions in which humans work."

James Reason, professor of psychology at the University of Manchester

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Transforming Education & Practice

to Improve DiagnosisRegister now for #SIDM2020

Diagnostic Error in Medicine 13th Annual International Conference

taking place virtually October 19-21

• Learn about the latest developments in diagnostic quality and safety research, education and practice improvement.

• Earn continuing education credits (as a professional).

• Network with your peers and join a community of clinicians, researchers, quality improvement experts and patients and families working to reduce harm from diagnostic error.

Valued SIDM members receive a reduced conference rate, and non-members who register for the full conference will receive a complimentary SIDM membership through June 30, 2021.

Discount bundle registrations available!

www.improvediagnosis.org/sidm2020

Resources

Society to Improve Diagnosis in Medicine

NAM Improving Diagnosis in Health Care

ECRI Institute Report

“The Big Three” Research

Diagnostic Error Fishbone

HRET Change Package

Gerry Castro, PhD, MPH, PMPDirector of Quality Improvementgerry.castro@improvediagnosis.org

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