Hosted by: Constellation®, Iowa Healthcare Collaborative + Society to Improve Diagnosis in Medicine

KEYNOTE: DEFINING THE LANDSCAPE AND SETTING THE AGENDA FOR DIAGNOSTIC ERRORS: WHAT WILL IT TAKE TO ACHIEVE DIAGNOSTIC EXCELLENCE

David Newman-Toker, Director, Armstrong Institute Center for Diagnostic Excellence, Johns Hopkins Medicine

Diagnostic errors are almost certainly the most common, most costly and most catastrophic of medical errors. Despite this, they were largely ignored for the first two decades of the patient safety movement era. Over the past five years since the publication of the National Academy of Medicine report on Improving Diagnosis in Healthcare, this has finally begun to change. In this session, Dr. David Newman-Toker reviewed the scope of the problem, the complexity of causes and the need for multi-faceted solutions at provider, organizational and system levels.

EXPLORING SOLUTIONS TO ADDRESS DIAGNOSTIC ERROR

Dana Siegal, RN, CPHRM, CPPS, Director, Patient Safety Services, CRICO Strategies

Diagnostic errors are typically driven by two primary causes: cognitive and system failures. In this session, Dana Siegal shared national medical professional liability claim data illustrating the prevalence of these challenges in diagnostic error cases. She presented solutions to both sources of error, including raising awareness regarding cognitive biases and highlighting decision-support tools to aid in this process. Systems-based solutions for closing loops in referral and test result management processes were also discussed. 

THE EMOTIONAL AND ORGANIZATIONAL COST OF HARM

Julia Prentice, PhD, Research Director, Betsy Lehman Center for Patient Safety 

Medical error can have significant emotional, financial, physical and socio-behavioral impacts, including reduced healthcare trust and avoidance. The Massachusetts Betsy Lehman Center for Patient Safety fielded a statewide survey to increase their understanding of how patients and families experience medical error. This session will review the data examining the long-term impact of medical error, discuss the relationship between open communication and long-term impacts and identify current tools for communication and resolution best practices.

KEYNOTE: THE POWER OF PARTNERSHIP: HOW PATIENTS CAN – AND DO – PARTNER TO IMPROVE DIAGNOSIS IN MEDICINE

Suzanne Schrandt, Senior Engagement Advisor, Society to Improve Diagnosis in Medicine

This session described current practices in patient engagement to improve diagnosis in medicine. Patients, particularly those who have been affected by a diagnostic error, play a critical role in eliminating diagnostic error through research, policy, patient education and quality improvement. Patients can provide first-hand insights from their experience that no one else in the health care ecosystem can. Appropriately facilitating the involvement of patient partners can yield important gains in this critical work.

CANDOR: NORMALIZING COMPASSIONATE HONESTY AFTER UNEXPECTED HARM

Timothy McDonald, MD, JD, Chief Patient Safety and Risk Officer, RLDatix, Professor of Law, Loyola University and Bruce Lambert, PhD, Professor, Department of Communication Studies, Director, Center for Communication and Health, Northwestern University

Candor is a powerful tool that works to maintain open and honest communication with patients and families after a harm event occurs. During this highly experiential session, attendees learned about the evolution of the health care industry’s response to patient harm and discussed empathetic and honest communication, including the disclosure of mistakes or errors. Attendees also gained a clearer understanding of the issues surrounding the emotional angst for members of the care team. 

PANEL DISCUSSION: EVOLUTION OF APPROACHES TO PATIENT HARM HEAL/CANDOR

Moderator: Tom Evans, MD, FAAFP, President and CEO, Iowa Healthcare Collaborative

Panelists: Timothy McDonald, MD, JD, Chief Patient Safety and Risk Officer, RLDatix, Professor of Law, Loyola University; Bruce Lambert, PhD, Professor, Department of Communication Studies, Director, Center for Communication and Health, Northwestern University; Shelly Davis, JD, BSN, Director of Early Intervention, Constellation and Laurie Drill-Mellum, MD, MPH, Chief Medical Officer, Constellation

This panel discussion focused on the evolution of approaches for responding to patient harm. During the panel, speakers discussed honest communication, including the disclosure of mistakes or errors, and the support that clinicians and patients need after a diagnostic error or harm event occurs. Panelists also shared what brought them to the work on Communication and Resolution Programs (CRPs).

KEYNOTE: FROM PRINCIPLE TO PRACTICE: HOW COMMUNICATION, PATIENT ENGAGEMENT, AND LEARNING CAN PREVENT AND RESPOND TO DIAGNOSTIC ERRORS

Thomas H. Gallagher, MD, Professor, Department of Medicine, Professor, Department of Bioethics and Humanities, University of Washington

Experts on improving diagnosis in medicine have long recognized the important role that effective communication, patient engagement and learning can play in preventing diagnostic errors. CRPs emphasize how transparent communication, collaboration with patients and families, and accountable learning are critical to responding when care has gone awry. Bringing the Improving Diagnosis and CRP communities together could enhance the effectiveness of both streams of work. Yet, both fields also suffer from the challenges of turning these principles into reliable practices. This presentation reviewed how the integration of concepts around improving diagnosis, coupled with high reliability and CRPs, could substantially accelerate the progress of these critical and related areas.

FOLLOW-UP SYSTEM FAILURES: STOP DROPPING THE BALL 

Laurie C. Drill-Mellum, MD, MPH, Chief Medical Officer, Constellation; Missy Lindow, Director of Clinic Operations and Access, Lakewood Health System; Mary Theurer, Lakewood Health System Board and Andrew Olson, MD, Associate Professor, University of Minnesota Medical School

Follow-up system failures contribute to over half of Constellation’s outpatient diagnostic error malpractice claims. Even when appropriate clinical steps are taken to lead to a correct diagnosis, diagnostic errors due to failures in follow-up and care coordination persist. This session provided an overview of Constellation’s malpractice claim data and illustrated how, with the support of the Minnesota Alliance for Patient Safety (MAPS), Lakewood Health System used co-design to create a new process—with community members and patients—to minimize the possibility of test result follow-up system failures upon discharge from the Emergency Department.

TAKING ACTION TO CLOSE THE LOOP ON DIAGNOSTIC ERROR: A CONSTELLATION AND SIDM COLLABORATIVE

Gerry Castro, MPH, Quality Improvement Program Manager, Society to Improve Diagnosis Medicine

This virtual Collaborative is a joint effort of Constellation^® and the Society to Improve Diagnosis in Medicine (SIDM) focused on improving the diagnostic process during two of the three key stages: tests and results processing and follow-up and coordination. The Collaborative is a virtual community managed by SIDM to share work, update on progress, raise questions and join conversations improving the diagnostic process and reducing preventable harm. Learn more.