How to Close the Loop on Diagnostic Error

January 24, 2022

By: Janet P. Mangun, MT(ASCP), MSA, CPHRM, SIDM Quality Improvement Consultant and Gerard M. Castro, PhD, MPH, PMP, SIDM Director of Quality Improvement

Taking action to close the loop on diagnostic error: A Constellation & SIDM Collaborative

Diagnostic errors are frequent, costly and largely preventable. Through an analysis of our malpractice claims, Constellation discovered that diagnostic error is the #1 most costly and #3 most frequent allegation made against policyholder organizations.

The majority of these diagnostic error harm events arise from care delivered in the outpatient setting, and over half involve follow-up system failures, meaning that accurate and timely diagnosis depends nearly as much on the health care team and systems as it does on the diagnosticians themselves.

Constellation and the Society to Improve Diagnosis in Medicine (SIDM) recently launched a year-long quality improvement (QI) Collaborative focused on improving the diagnostic process during two of the three key stages of the diagnostic process of care: tests and results processing, and follow-up and coordination.

The Collaborative is a virtual community where participants have begun sharing their QI work, raising questions, receiving consultative support and engaging in shared learning. Over the course of the year, Collaborative participants will strive to reduce diagnostic error caused by follow-up system failures in their organization.

The Society to Improve Diagnosis in Medicine

As the only organization focused solely on reducing diagnostic error and improving the accuracy and timeliness of diagnosis, SIDM strives to catalyze and lead change to eliminate harm from diagnostic error in partnership with patients, their families, the health care community and every interested stakeholder. Visit www.improvediagnosis.org to learn more and access additional resources and information.

Collaborative participant improvement projects and progress

Here’s a sample of the QI projects Collaborative organizations are working on:

  • After completing Constellation’s Diagnostic Error Risk Assessment and receiving their results, a critical access hospital is taking a proactive approach to the process of reporting and communicating critical test results in the emergency department and in the perioperative setting among clinicians and patients to ensure appropriate documentation and patient follow up.

    After finding numerous variations in processes and procedures for reporting and communicating critical test results in the targeted settings, they have initiated process improvements, education for team members, and monitoring of the new process to ensure standardized practices are being followed to avoid a serious diagnostic patient safety event in the future.
  • Based upon clinician complaints, a participating health system is working to ensure lab results sent to non-system clinicians are received in a timely manner so the results are available for a patient’s follow-up appointment. The organization is searching for IT tools that can assist with better communication and documentation of receipt of test results by non-system clinicians. Clinic personnel and a representative from the organization’s Patient Family Engagement Committee are included as stakeholders in this improvement work.

    This organization is also developing a standardized process for telephone triage so information captured in the conversation with the patient is followed up in a timely manner to reduce the risk of a diagnostic error. Once procedures for telephone triage are developed and standardized, the organization’s case managers and patient navigators will be utilized to ensure appropriate patient follow-up and referral.
  • Utilizing claim data, an academic health system is seeking to improve communication of critical test results reported by Radiology to ensure the ordering clinician responsible for patient communication and follow-up is notified. Process mapping for receipt of critical test results is planned to determine where gaps in the flow of communication are occurring. The organization’s EHR vendor will be contacted to see if they have built any clinical decision support (CDS) tools for critical test results that would ensure the appropriate clinician has been notified and patient follow-up has occurred.
Challenges, barriers and lessons learned

We asked Collaborative participants to share the challenges, barriers and lessons learned thus far along their QI journey. Here’s what they said:

“Obtaining good data to establish baseline performance and measure progress is a challenge in both large and small hospitals. Furthermore, IT support is limited both in number and expertise of personnel. Data can be flawed by multiple points of and inconsistent input, lack of discrete capture fields, etc. Involving IT as a member of the core QI team is essential to the redesign and building of solutions.”

“Getting front-line clinician buy-in is another critical component to success. Make sure to involve clinicians in both the planning for as well as the developing of process change for improvement. Knowing that they have a say in the changes that will be made can make a huge difference in their engagement.”

“Planning a QI intervention that involves multiple units and personnel can be overwhelming. Step back an narrow the scope and focus to make the work and effort more manageable.”

“It is important to monitor a process change or redesign periodically to ensure it is sustainable over time and the desired outcomes are occurring.”

“Personnel changes in the QI team and with other key stakeholders, either due to COVID-19 or other circumstances, have seriously impeded progress in this work. Assistance from graduate students who need a capstone project or similar work for their educational requirements may be the one way of obtaining additional help.”

We need your help!

We are looking for a gap analysis tool on test result follow-up specifically for small, critical access hospitals. Anyone willing to share tools and ideas should contact Gerry Castro, SIDM’s Quality Improvement Director at gerry.castro@improvediagnosis.org


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