Taking Action to Close the Loop on Diagnostic Error: Virtual Collaborative
A diagnosis delay caused by a system failure
A primary care physician (PCP) saw a 45-year-old woman for a routine exam and ordered a screening mammogram. The radiologist interpreted the mammogram, noted a questionable area in the left breast and recommended additional imaging to rule out breast cancer. However, a system-generated letter to the patient and report to the ordering PCP were not sent due to a failure in the reporting technology.
One year later, the woman saw her PCP complaining of a palpable lump in her left breast. Following a biopsy, she was diagnosed with breast cancer. A root cause analysis of the delay in diagnosis revealed that a software update triggered a failure in the reporting system and that many patients could have been affected by the communication system failure.
Diagnostic errors are frequent, costly and largely preventable
An analysis of Constellation® malpractice claims reveals that diagnostic errors are frequent, costly and preventable. We found that diagnostic error is the #3 most frequent and #1 most costly allegation. The majority of claims arose from care delivered in the outpatient setting and almost half of these were high severity injuries.
“We found that over half of our outpatient diagnostic error claims involved follow-up system failures like this breast cancer case. This led us to our ‘aha’ moment, that accurate and timely diagnosis depends nearly as much on the health care team and systems as it does on the diagnosticians themselves.”Dr. Laurie Drill-Mellum, Chief Medical Officer at Constellation
Taking Action to Close the Loop on Diagnostic Error: A Constellation and SIDM Collaborative
Constellation and the Society to Improve Diagnosis in Medicine (SIDM) are partnering to launch a year-long, virtual quality improvement (QI) community 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 Taking Action to Close the Loop on Diagnostic Error Collaborative will use an Institute for Healthcare Improvement (IHI) learning model including virtual education sessions, time for workflow improvement and data collection, and reporting.
We will kick off the Collaborative with a learning session on Day 3 of the Working Together to Improve Diagnosis Virtual Conference (May 25-27th, 2021).
From June 2021 – June 2022, through a series of webinars, coaching calls and virtual meetings, participants should be able to show improvement in a QI project aimed at closing the loop on diagnostic error in their organization.
What’s in it for health care organizations?
- Virtual QI community with expert QI Coach/QI Advisor
- Educational webinars and QI working calls
- Improved diagnostic processes
- Reduction in patient harm, inefficiencies and financial burdens
- Enhanced market reputation
To apply, submit an email to Collaborative@ConstellationMutual.com by June 1, 2021. Early applicants will be given priority as space is limited.
The cost for participation is valued at $2,000. Due to the financial constraints on health care organizations in the COVID-19 environment, Constellation is now waiving the fee for participation.
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