A Simple Way to Reduce Diagnostic Errors

A Simple Way to Reduce Diagnostic Errors

Electronic triggers can help make diagnostic errors a thing of the past.

Great strides have been made in the last decade to reduce serious safety events. Hospital-acquired conditions previously considered unavoidable are now considered unacceptable, such as venous thrombi and ventilator-associated pneumonia. However, many adverse events are still perceived as unfortunate consequences without solutions.

In an aggregate review of serious safety events from the past six years at Children’s Hospital Colorado, one common contributor to stood out: diagnostic errors. The available resources and diagnostic safety experts that are needed to address adverse events arising from missed, delayed and erroneous diagnoses lag considerably behind those for traditional hospital-acquired conditions. There are two main reasons for this.

First, common cause analysis of serious adverse events provides neither sufficient data to describe the scope of harm due to diagnostic error nor the opportunities to reduce harm. Common cause evaluations reveal recurring concerns with diagnostic reasoning, but the diagnostic pitfalls for one event are likely irrelevant to the others.

For example, the factors leading to misinterpretation of a normal blood gas in a child in respiratory distress are almost certainly different from those associated with not recognizing vital signs of evolving sepsis. Furthermore, a focus on only serious adverse events excludes near-misses and minor harm, though most parents would consider even minor harm unacceptable.

Second, while passive incident reporting systems can accumulate data, clinicians do not always report diagnostic errors—whether it’s because of a lack of error recognition, fear of punitive repercussions, or fear of judgment from peers. In addition, clinicians, nurses and other hospital staff may be reluctant to report diagnostic errors because the diagnostic process is canonically and legislatively codified as the sole purview of physicians, nurse practitioners and physician assistants.

One step toward a solution

Since the release of “Improving Diagnosis in Healthcare” by the National Academy of Medicine in 2015, institutional diagnostic safety leaders have begun to search for new ways to promote reporting and identify patterns among diagnostic errors. For example, a project at Cincinnati Children’s Hospital Medical Center created infrastructure and processes to encourage pediatric hospitalists to submit possible diagnostic learning opportunities identified during their time on service. Nationwide Children’s Hospital has developed a Diagnostic Error Index to aggregate data from numerous sources of case review within their institution.

Despite such innovative programs, capturing the burden of diagnostic error often remains a passive endeavor—at least until a patient suffers serious harm. Given all the possible missed opportunities for an accurate and timely diagnosis across any children’s hospital, where does a patient safety team start to address the two major problems?

The Children’s Colorado diagnostic safety journey started in earnest after a young boy died from being repeatedly misdiagnosed in the hospital’s urgent care network. While the root cause analysis clearly identified diagnostic error as a root cause, solutions were elusive. So, we devised an e-trigger in the electronic medical record to evaluate patients admitted to the tertiary care center within 14 days of a visit to any of our emergency department or urgent care locations.

Rather than relying on passive reporting, e-triggers identify episodes of care or other discrete events that may reveal quality of care concerns in the diagnostic process. We focus on cases where the diagnosis at the initial and admission encounters were different, which potentially indicates a missed opportunity.

In four years, we have screened approximately 2,800 charts, performed a structured review on almost 25% of those cases and identified 136 diagnostic errors. Notably, out of the 93 cases in the first two years of data, only two were also reported through the hospital’s incident reporting system. The emergency department’s review committee knew of only five.

This experience shows that a simple change from a passive to active approach can help address the problem diagnostic errors. Although it is only one part of the solution, electronic triggers can inform solutions that get us one step closer to making diagnostic errors unacceptable rather than unavoidable.

Grubenhoff helped develop the Child Health Patient Safety Organization’s Diagnostic Safety Toolkit to help hospitals improve communication and enhance safety.

We want to hear from you! Send us your questions, comments or ideas.
Get in touch.

Written By:
Joe Grubenhoff, M.D., MSCS
Medical Director of the Diagnostic Safety Program, Children’s Colorado
Written By:
Fidelity M. Dominguez, BSN, RN, CPEN
Process Improvement Lead of the Diagnostic Safety Program, Children’s Hospital Colorado

Read the Latest Issue of Children's Hospitals Today

Don't miss the latest industry news, insights and ideas.

View