Five Steps Organizations Can Take to Reduce the Top Drivers of Patient Harm

May 1, 2024

In April, we hosted Working Together to Improve Patient Outcomes, a virtual conference in partnership with Iowa Healthcare Collaborative. The conference featured the nation’s leading experts who spoke about reducing the top drivers of patient harm—diagnostic, surgical, and obstetrical errors—and the importance of effectively communicating with patients and their families following a harm event. This event included key learnings and pointed the way toward reducing and responding to the top drivers of patient harm.

Day One: Reducing diagnostic harm

Diagnostic errors are frequent and costly and occur across the continuum of care. Tejal Gandhi, MD, explored the importance of diagnostic safety, the epidemiology of diagnostic errors, contributing factors, and the impact of inequities on these errors. She spoke about broadening the definition of diagnostic harm to include not just physical harm but emotional/psychological, financial, and socio-behavioral harm. Lastly, she described foundational strategies to drive the reduction of diagnostic errors.

Hardeep Singh, MD, spoke about the need to engage physicians in diagnostic safety by changing the conversation from “Report your errors” to “What did you learn during the diagnostic process that led to an adverse event?” He noted that physicians’ diagnostic accuracy and confidence are not calibrated, and feedback on accuracy is essential. Dr. Singh explored solutions, including how clinicians and healthcare organizations can measure and learn from their diagnostic errors. He identified several tools to achieve diagnostic excellence: The SAFER DX Checklist 10 High-Priority Organizational Practices for Diagnostic Excellence, Measure DX: A Resource To Identify, Analyze, and Learn From Diagnostic Safety Events, and Calibrate DX.

Gordon Schiff, MD, and Thomas Gallagher, MD, subject matter experts in diagnostic safety and responding to harm events with transparency, accountability, and learning, discussed an exciting new project that aims to support patients who have experienced a delayed cancer diagnosis, with a special emphasis on historically marginalized patients. Dr. Gallagher also noted physicians struggle with responding to harm events for several reasons, including receiving mixed messages about communicating with patients and families, and lacking the tools and training needed.

Day Two: Reducing surgical harm

Robin Blackstone, MD, noted that we have come to understand surgery as a complex system that begins before the actual operating room event and consists of key factors in environmental design and distraction, social factors regarding teamwork and communication, and supervisory factors involving care teams and organizational elements. Looking back to examine error with this wider lens diminishes the culture of shame and blame that occurs with error. Instead, the focus lands on the analysis of the true source of error within the system and culture of care.

Kourtney Kemp, MD, Curi Board member, shared that the first few years of a surgeon’s career can be critical and early career challenges can plague them for the remainder of their careers. These challenges can be debilitating, personally isolating, and could lead to further adverse events. She discussed how to create a cohesive surgical team by building trust through challenging times, encouraging conflict, ensuring all voices on the team are heard, and implementing a comprehensive new surgeon onboarding program.

Our communication and resolution panel was led by Tom Evans, MD, and included Curi’s Director of Early Intervention, Shelly Davis, JD, along with Thomas Gallagher, MD, Frank KornStephen Pearlman, MD, and Larry Smith, MD. The panel delved into the factors needed to create a successful communication and resolution program (CRP)—leadership support, useful data, a tie to your organization’s mission and values, a mapping of the process, and engagement of all physicians and team members.

Day Three: Reducing maternal health harm

Komal Bajaj, MD, cited two noteworthy facts about maternal harm. First, 80% of maternal mortality can be prevented. Second, diagnostic errors are three times more likely to cause complications in pregnant women, with the most frequently reported events involving a delay in diagnosis or treatment. She explored various strategies to apply a diagnostic safety lens to obstetrical (OB) care and outlined tangible next steps to make progress in this emerging area. She noted many no-cost, evidence-based resources, toolkits, and checklists available to improve OB care.

Shad Deering, MD, identified how practicing with simulation for OB emergencies can not only prepare teams for urgent situations but can also decrease errors related to missed diagnoses and organizational issues, ultimately improving maternal and fetal outcomes. He discussed existing evidence and how it needs to be used moving forward as a part of comprehensive effort to improve care.

Charity Watkins, PhD, brought the patient perspective into focus. She noted that the U.S. has the highest rate of maternal morbidity among other high-income nations. Black women are especially impacted; they face failed shared decision-making, delays in treatment and referrals, and ignored symptoms, and their concerns may not be addressed. Storytelling about these cases brings light to the problem. She utilized a patient case example to explore how interpersonal and institutionalized racism may have been evident within evaluation, diagnosis, and treatment. Additionally, this presentation examined a less explored aspect of severe maternal morbidity: life after diagnosis.

Five steps physicians and healthcare organizations can take today to reduce patient harm

  1. Gain leadership support for cultural change to effectively address diagnostic, surgical, and maternal harm.
  2. Implement a new surgeon onboarding program.
  3. Provide tools, training, and role-playing practice for physicians and care teams to enable them to have transparent and honest communication with patients and families following a harm event.
  4. Use simulation to learn, prepare, and practice OB emergencies without putting patients at risk.
  5. Engage patients to become part of your performance improvement team and solicit stories from your Patient and Family Advisory Councils.

Curi’s risk mitigation resources and guidance are offered for educational and informational purposes only. This information is not medical or legal advice, does not replace independent professional judgment, does not constitute an endorsement of any kind, should not be deemed authoritative, and does not establish a standard of care in clinical settings or in courts of law. If you need legal advice, you should consult your independent/corporate counsel. We have found that using risk mitigation efforts can reduce malpractice risk; however, we do not make any guarantees that following these risk recommendations will prevent a complaint, claim, or suit from occurring, or mitigate the outcome(s) associated with any of them.

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