Register      Login
Australian Health Review Australian Health Review Society
Journal of the Australian Healthcare & Hospitals Association
RESEARCH ARTICLE

An organisational approach to improving diagnostic safety

Ian A. Scott A B * and Carmel Crock C D
+ Author Affiliations
- Author Affiliations

A Department of Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Ipswich Road, Brisbane, Qld 4102, Australia.

B University of Queensland, Qld, Australia.

C Emergency Department, Royal Victorian Eye and Ear Hospital, Melbourne, Vic., Australia.

D University of Melbourne, Vic., Australia.

* Correspondence to: ian.scott@health.qld.gov.au

Australian Health Review 47(3) 261-267 https://doi.org/10.1071/AH22287
Submitted: 15 December 2022  Accepted: 3 March 2023   Published: 27 March 2023

© 2023 The Author(s) (or their employer(s)). Published by CSIRO Publishing on behalf of AHHA.

Abstract

Diagnostic error affects up to 10% of clinical encounters and is a major contributing factor to 1 in 100 hospital deaths. Most errors involve cognitive failures from clinicians but organisational shortcomings also act as predisposing factors. There has been considerable focus on profiling causes for incorrect reasoning intrinsic to individual clinicians and identifying strategies that may help to prevent such errors. Much less focus has been given to what healthcare organisations can do to improve diagnostic safety. A framework modelled on the US Safer Diagnosis approach and adapted for the Australian context is proposed, which includes practical strategies actionable within individual clinical departments. Organisations adopting this framework could become centres of diagnostic excellence. This framework could act as a starting point for formulating standards of diagnostic performance that may be considered as part of accreditation programs for hospitals and other healthcare organisations.

Keywords: diagnosis, errors, framework, organisation, performance, program, safety, standards.


References

[1]  Balogh EP, Miller BT, Ball JR, editors. Improving Diagnosis in Health Care. National Academies Press; 2015.

[2]  Graber ML. The incidence of diagnostic error. BMJ Qual Saf 2013; 22 ii21–ii27.
The incidence of diagnostic error.Crossref | GoogleScholarGoogle Scholar |

[3]  Victorian Managed Insurance Authority. Better Patient Safety: Preventing patient harm in emergency and urgent care settings. 2022. Available at VMIA Preventing patient harm in emergency and urgent care settings 2022 [accessed 6 November 2022].

[4]  Gupta A, Harrod M, Quinn M, et al. Mind the overlap: How system problems contribute to cognitive failure and diagnostic errors. Diagnosis 2018; 5 151–156.
Mind the overlap: How system problems contribute to cognitive failure and diagnostic errors.Crossref | GoogleScholarGoogle Scholar |

[5]  McGlynn EA, McDonald KM, Cassel CK. Measurement is essential for improving diagnosis and reducing diagnostic error: a report from the Institute of Medicine. JAMA 2015; 314 2501–2502.
Measurement is essential for improving diagnosis and reducing diagnostic error: a report from the Institute of Medicine.Crossref | GoogleScholarGoogle Scholar |

[6]  Scott IA, Crock C. Diagnostic error: incidence, impacts, causes and preventive strategies. Med J Aust 2020; 213 302–305.e2.
Diagnostic error: incidence, impacts, causes and preventive strategies.Crossref | GoogleScholarGoogle Scholar |

[7]  Singh H, Upadhyay DK, Torretti D. Developing health care organizations that pursue learning and exploration of diagnostic excellence: an action plan. Acad Med 2020; 95 1172–1178.
Developing health care organizations that pursue learning and exploration of diagnostic excellence: an action plan.Crossref | GoogleScholarGoogle Scholar |

[8]  Henriksen K, Brady J. The pursuit of better diagnostic performance: a human factors perspective. BMJ Qual Saf 2013; 22 ii1–ii5.
The pursuit of better diagnostic performance: a human factors perspective.Crossref | GoogleScholarGoogle Scholar |

[9]  Giardina TD, Shahid U, Mushtaq U, et al. Creating a learning health system for improving diagnostic safety: Pragmatic insights from US health care organizations. J Gen Intern Med 2022; 37 3965–3972.
Creating a learning health system for improving diagnostic safety: Pragmatic insights from US health care organizations.Crossref | GoogleScholarGoogle Scholar |

[10]  Berenson R, Singh H. Payment innovations to improve diagnostic accuracy and reduce diagnostic error. Health Aff (Millwood) 2018; 37 1828–1835.
Payment innovations to improve diagnostic accuracy and reduce diagnostic error.Crossref | GoogleScholarGoogle Scholar |

[11]  Lipitz-Snyderman A, Kale M, Robbins L, et al. Peers without fears? Barriers to effective communication among primary care physicians and oncologists about diagnostic delays in cancer. BMJ Qual Saf 2017; 26 892–898.
Peers without fears? Barriers to effective communication among primary care physicians and oncologists about diagnostic delays in cancer.Crossref | GoogleScholarGoogle Scholar |

[12]  Lavoie CF, Plint AC, Clifford TJ, et al. “I never hear what happens, even if they die”: a survey of emergency physicians about outcome feedback. CJEM 2009; 11 523–528.
“I never hear what happens, even if they die”: a survey of emergency physicians about outcome feedback.Crossref | GoogleScholarGoogle Scholar |

[13]  McDonald KM, Bryce CL, Graber ML. The patient is in: Patient involvement strategies for diagnostic error mitigation. BMJ Qual Saf 2013; 22 ii33–ii39.
The patient is in: Patient involvement strategies for diagnostic error mitigation.Crossref | GoogleScholarGoogle Scholar |

[14]  Singh H, Sittig DF. Advancing the science of measurement of diagnostic errors in healthcare: the Safer Dx framework. BMJ Qual Saf 2015; 24 103–110.
Advancing the science of measurement of diagnostic errors in healthcare: the Safer Dx framework.Crossref | GoogleScholarGoogle Scholar |

[15]  Sittig DF, Ash JS, Singh H. The SAFER guides: empowering organizations to improve the safety and effectiveness of electronic health records. Am J Manag Care 2014; 20 418–423.

[16]  Staal J, Hooftman J, Gunput STG, et al. Effect on diagnostic accuracy of cognitive reasoning tools for the workplace setting: systematic review and meta-analysis. BMJ Qual Saf 2022; 31 899–910.
Effect on diagnostic accuracy of cognitive reasoning tools for the workplace setting: systematic review and meta-analysis.Crossref | GoogleScholarGoogle Scholar |

[17]  Scott IA. Using information technology to reduce diagnostic error: still a bridge too far? Intern Med J 2022; 52 908–911.
Using information technology to reduce diagnostic error: still a bridge too far?Crossref | GoogleScholarGoogle Scholar |

[18]  Newman-Toker DE, Schaffer AC, Yu-Moe CW, et al. Serious misdiagnosis-related harms in malpractice claims. Diagnosis 2019; 6 227–240.
Serious misdiagnosis-related harms in malpractice claims.Crossref | GoogleScholarGoogle Scholar |

[19]  Bradford A, Shahid U, Schiff GD, et al. Development and usability testing of the Agency for Healthcare Research and Quality common formats to capture diagnostic safety events. J Patient Saf 2022; 18 521–525.
Development and usability testing of the Agency for Healthcare Research and Quality common formats to capture diagnostic safety events.Crossref | GoogleScholarGoogle Scholar |

[20]  Liberman AL, Newman-Toker DE. Symptom-Disease Pair Analysis of Diagnostic Error (SPADE): a conceptual framework and methodological approach for unearthing misdiagnosis-related harms using big data. BMJ Qual Saf 2018; 27 557–566.
Symptom-Disease Pair Analysis of Diagnostic Error (SPADE): a conceptual framework and methodological approach for unearthing misdiagnosis-related harms using big data.Crossref | GoogleScholarGoogle Scholar |

[21]  Smith MW, Davis Giardina T, Murphy DR, et al. Resilient actions in the diagnostic process and system performance. BMJ Qual Saf 2013; 22 1006–1013.
Resilient actions in the diagnostic process and system performance.Crossref | GoogleScholarGoogle Scholar |

[22]  Agency for Healthcare Research and Quality. Issue Briefs on Diagnosis. Available at AHRQ Papers on Diagnostic Safety Topics | Agency for Healthcare Research and Quality [accessed 5 November 2022].

[23]  Rosen M, Ali KJ, Buckley BO, Goeschel C. Leadership To Improve Diagnosis: A Call To Action. Rockville, MD: AHRQ; 2021. AHRQ Publication No. 20(21)-0040-5-EF.

[24]  The Leapfrog Group. Recognising Excellence in Diagnosis. Recommended Practices for Hospitals. July. 2022. Available at Recognizing Excellence in Diagnosis | Leapfrog (leapfroggroup.org) [accessed 5 November 2022].

[25]  Singh H, Khanna A, Spitzmueller C, Meyer AND. Recommendations for using the Revised Safer Dx Instrument to help measure and improve diagnostic safety. Diagnosis 2019; 6 315–323.
Recommendations for using the Revised Safer Dx Instrument to help measure and improve diagnostic safety.Crossref | GoogleScholarGoogle Scholar |

[26]  Singh H, Mushtaq U, Marinez A, et al. Developing the Safer Dx checklist of ten safety recommendations for health care organizations to address diagnostic errors. Jt Comm J Qual Patient Saf 2022; 48 581–590.
Developing the Safer Dx checklist of ten safety recommendations for health care organizations to address diagnostic errors.Crossref | GoogleScholarGoogle Scholar |

[27]  Singh H, Graber ML, Kissam SM, et al. System-related interventions to reduce diagnostic errors: a narrative review. BMJ Qual Saf 2012; 21 160–170.
System-related interventions to reduce diagnostic errors: a narrative review.Crossref | GoogleScholarGoogle Scholar |

[28]  Okafor N, Payne VL, Chathampally Y, et al. Using voluntary reports from physicians to learn from diagnostic errors in emergency medicine. Emerg Med J 2015; 33 245–252.
Using voluntary reports from physicians to learn from diagnostic errors in emergency medicine.Crossref | GoogleScholarGoogle Scholar |

[29]  Singh H, Giardina TD, Forjuoh S, et al. Electronic health record-based surveillance of diagnostic errors in primary care. BMJ Qual Saf 2012; 21 93–100.
Electronic health record-based surveillance of diagnostic errors in primary care.Crossref | GoogleScholarGoogle Scholar |

[30]  Lane KP, Chia C, Lessing JN, et al. Improving resident feedback on diagnostic reasoning after handovers: the LOOP Project. J Hosp Med 2019; 14 622–625.
Improving resident feedback on diagnostic reasoning after handovers: the LOOP Project.Crossref | GoogleScholarGoogle Scholar |

[31]  Danforth KN, Smith AE, Loo RK, et al. Electronic clinical surveillance to improve outpatient care: Diverse applications within an integrated delivery system. eGEMS 2014; 2 9
Electronic clinical surveillance to improve outpatient care: Diverse applications within an integrated delivery system.Crossref | GoogleScholarGoogle Scholar |

[32]  Kanter MH, Ghobadi A, Lurvey LD, et al. The e-Autopsy/e-Biopsy: a systematic chart review to increase safety and diagnostic accuracy. Diagnosis 2022; 9 430–436.
The e-Autopsy/e-Biopsy: a systematic chart review to increase safety and diagnostic accuracy.Crossref | GoogleScholarGoogle Scholar |

[33]  Schiff GD, Martin SA, Eidelman DH, et al. Ten principles for more conservative, care-full diagnosis. Ann Intern Med 2018; 169 643–645.
Ten principles for more conservative, care-full diagnosis.Crossref | GoogleScholarGoogle Scholar |

[34]  New South Wales Clinical Excellence Commission. Diagnostic error. Available at Diagnostic error - Clinical Excellence Commission (nsw.gov.au) [accessed 6 November 2022].

[35]  Diagnostic Safety Centres of Excellence. Agency for Healthcare Research and Quality. October. 2022. Available at www.ahrq.gov/patient-safety/diagnostic-excellence-grants/index.html [accessed 6 November 2022].