Joe Grubenhoff, M.D., M.S.C.S., recalls when he started medical school, patient safety wasn't a big part of the conversation—the assumption was that medical errors couldn't be causing that much of a problem. The medical community changed the thinking about patient safety and Grubenhoff, now associate medical director of clinical effectiveness at Children's Hospital Colorado, leads the hospital's effort to bring data to the forefront of identifying harm resulting from diagnostic errors.
The team is developing a method to identify patients who experienced harm from diagnostic errors in the emergency department (ED) using a combination of electronic health record (EHR) triggers and structured chart review. Here, he discusses the diagnostic safety project and how the approach to errors has changed.
Grubenhoff also worked with the Child Health Patient Safety Organization® to develop a toolkit to help diagnostic teams overcome the complexity of communication to improve diagnostic outcomes.
How have you seen the attitudes toward diagnostic errors evolve during your career?
You sort of get enculturated in this belief that if you make an error in judgement, you're a bad provider. As I learned about the psychology of critical reasoning, I realized science can explain a lot of these missteps and it makes it a lot less about the individual provider and more about the cognitive biases behind it. I'm hopeful we can remove some of the shame of making these missteps.
Has the chart review revealed a trend in diagnostic errors?
The most consistent error is mis-attributing headache to migraines and not pursuing other diagnoses. It's also common to blame belly pain on constipation. In the pediatric ED, the biggest risk is assuming super common problems cause all the problems. If we can demonstrate it's more than a one-off that a provider assumes a child has a migraine even though we've never really ruled out brain tumors, aneurysm bleeds and meningitis, we can study and learn how to systematically try to reduce it. We're talking about what we can do within the EHR for a patient who's never been diagnosed with a migraine. We might be able to get the provider to stop and think, "How confident am I in this diagnosis?"
What are your expectations for the future of diagnostic safety?
We need to have more conversation around the discomfort of diagnostic error feedback. It's hard to have a conversation that allows the receiver of feedback to hear it in the spirit in which it's given—we're trying to make the system safer and the patients safer. The next step is to create systems that identify diagnostic errors and then use the information in a psychologically safe way. Let providers get better without making them feel ashamed. It's going to require people who are respected as solid diagnosticians to share their error experiences so others can see you can still be a great clinician even when you make an error.
