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How Transparency, Accountability & Learning Can Improve Diagnosis
April 7, 2021
A 52-year-old man complaining of nausea and gnawing pain in his stomach presented to his primary care clinic and was examined by a physician assistant (PA). The PA diagnosed epigastric pain and documented a plan to order tests to rule out a potentially serious condition if the symptoms continued. The man returned to the clinic four weeks later complaining of epigastric pain for the past several days, that had worsened in the last 24 hours. A family physician (FP) saw him at this visit and diagnosed gastroesophageal reflux disease (GERD), prescribed medication and recommended a follow-up appointment in six to eight weeks. No testing was ordered. Later that afternoon, the man collapsed at home and an ambulance was called. Efforts to resuscitate him were unsuccessful, and he died. The autopsy identified coronary artery disease.
At the time, the clinic did not have a process for transparent communication after a harm event, and there was no early resolution program in place. Perhaps because of this, the family filed a malpractice lawsuit against the FP and clinic alleging failure to diagnose a serious heart condition. The experts who reviewed the care were critical of the FP for failing to reevaluate the man’s symptoms, expand the differential diagnosis list to consider a potentially serious cardiac condition and order tests.
The lawsuit was settled with a payment on behalf of the FP and clinic after two years of litigation.
Constellation® malpractice claim data
According to the Society to Improve Diagnosis in Medicine (SIDM), diagnostic errors affect an estimated 12 million Americans each year and likely cause more harm than all other medical errors combined. An analysis of Constellation malpractice claims reveals that diagnostic errors are frequent, costly and preventable.
In our claim analysis, we found that diagnostic error is the #3 most frequent allegation and #1 most costly. The majority of claims arose from care delivered in the outpatient setting and nearly half of these were high severity injuries. The top missed diagnoses in outpatient claims were cancer – primarily breast, lung and skin – vascular conditions and infections.
To map out and understand where breakdowns in diagnostic processes most commonly occur, we leveraged CRICO Strategies 12-step diagnostic process of care framework which is comprised of three major stages: Initial Diagnostic Assessment, Testing & Results Processing, and Follow-up & Coordination. Over two-thirds (69%) of diagnostic errors in our outpatient claims began with issues during the initial diagnostic assessment. One-fifth of cases (23%) had issues with testing and results processing and over half (52%) had problems with follow-up care and coordination. The mapping of diagnostic process breakdowns in our claims allowed us to outline tools and risk mitigation strategies targeted at improving diagnosis and share these with our customers.
Over three half-days, industry experts from across the nation shared best practices and successes for improving diagnostic processes in health care organizations. The conference also emphasized the importance of communication after a harm event. Conference recordings are now available on demand.