Reducing Diagnostic, Surgical, and Maternal Health Harm Events

Working Together to Improve Patient Outcomes took place on April 2—4, 2024, and highlighted the impact that harm events from the top drivers of malpractice claims—diagnostic error, surgical treatment, and obstetrical treatment—have for physicians, healthcare providers, organizations, and patients. Attendees gained valuable insights to understand why allegations occur, identify opportunities for improvement, and recognize how early intervention provides a better way forward. 

Agenda Recap & Session Recordings

Keynote: Advancing Zero Harm – Time to Focus on Safe Diagnosis

Tejal K. Gandhi, MD, MPH, CPPS, Chief Safety and Transformation Officer, Press Ganey

The session began with a brief overview of the current state of patient safety, as well as a broader definition of harm. The session then explored the importance of diagnostic safety, epidemiology of diagnostic errors, contributing factors, as well as the impact of inequities on these errors. Lastly, foundational strategies to drive
reduction of these errors were described.

Advancing Science, Practice, and Policy for Reducing Diagnostic Errors in Medicine

Hardeep Singh, MD, MPH, Chief, Health Policy, Quality and Informatics Program, Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, and Baylor College of Medicine

The session began with a brief overview of the current understanding of diagnostic error in medicine and its cognitive and systems-related contributing factors, approaches to understanding its complexity, and methods to identify diagnostic errors in clinical practice. The session then explored solutions, including how clinicians and healthcare organizations can measure and learn from diagnostic errors and what potential interventions can be used to achieve diagnostic excellence.

Achieving Better Cancer Diagnosis Through Transparency, Accountability, and Patient Support

Thomas H. Gallagher, MD, MACP, Professor and Associate Chair, Department of
Medicine, University of Washington, and Executive Director, Collaborative for
Accountability and Improvement, and Gordy Schiff, MD, Associate Director of Brigham and Women’s Center for Patient Safety Research and Practice, Associate Professor of Medicine and Quality and Safety Director, Harvard Medical School

Delays in the diagnosis of cancer are too common. For patients diagnosed with advanced stage cancers, particularly those with symptoms or findings that may represent missed opportunities for earlier diagnosis, this can be devastating. In this session, we brought together expertise in both diagnostic safety and responding to problems in healthcare with transparency, accountability, and learning. We discussed an exciting new project that aims to identify, learn from, and support patients who have experienced a delayed cancer diagnosis, with a special emphasis on historically marginalized patients.

Keynote: Reducing Surgical Error – Achieving a Culture of Zero Error

Robin Blackstone, MD, FACS, Certified Diplomate in Obesity Medicine, CEO, Blackstone Health, Corporate Board Director, Health Futurist

Surgery is often thought of as a unique event performed by a surgeon on a person whose medical problem is solved by the procedure. When a surgical error occurs, the patient is harmed, and that harm often means long-term complications and repercussions. Rather than the view of the surgeon as the captain of a ship, we come to understand surgery as a complex system that begins prior to the actual operating room event, consists of key factors in environmental design and distraction, social factors regarding teamwork and communication, and supervisory factors involving care teams and organizational elements. Drawing back to examine error with this wider lens diminishes the culture of shame and blame that occurs with error and can focus on the analysis of the true source of error within the system and culture of care. The goal: establish a culture that produces zero error.

Reducing Surgical Error: Onboarding Physicians & Healthcare Professionals

Kourtney Kemp, MD, FACS, General Surgeon, Curi Board Member

The first few years of a physician’s career can be critical for first impressions amongst colleagues, staff, and patient communities. Early career challenges may plague physicians for the remainder of their careers, which can be debilitating, personally isolating, and could lead to further adverse events. There continue to be changes in medicine, business, and life that will require adaptability to succeed. Structuring a team with healthy conflict resolution, accountability, and trust is imperative. A cohesive team results in optimal outcomes and improved patient experiences. High-quality patient care is dependent on the future sustainability of our physicians and healthcare professionals.

Panel: Why Early Intervention is Critical to Care Teams and Organizations

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

Panelists: Shelly Davis, JD, BSN, Director, Early Intervention, Curi, Thomas H. Gallagher, MD, MACP, Professor and Associate Chair, Department of Medicine, University of Washington, Professor, Department of Bioethics and Humanities, University of Washington, Executive Director, Collaborative for Accountability and Improvement, Frank Korn, Director Risk Management, Dartmouth Hitchcock Medical Center, Stephen Pearlman, MD, MSHQS, Professor of Pediatrics, Jefferson Medical College, Larry L. Smith, JD, Vice President, Risk Management Services MedStar Health

Communication and resolution programs go by many names, including CRP, CANDOR, and early intervention, and have a goal to ensure that patients, families, and healthcare providers are supported after harm events; that communication is transparent and respectful; that organizations learn from events and improve patient safety as a result; and that when it’s appropriate, financial and non-financial compensation is offered. Promising research shows that when healthcare organizations partner with their medical malpractice liability insurer to intervene early after patient harm events, the result is quicker resolution, lower costs, and faster healing for all involved.

Keynote: Promoting Diagnostic Excellence in Maternal Health

Komal Bajaj, MD, MS-HPEd, Chief Quality Officer of NYC Health + Hospitals/Jacobi/
NCB, Clinical Director for NYC Health + Hospitals Simulation Center

Severe maternal morbidity and maternal mortality (SMM/MM) continues to be a public health crisis with increasing rates despite multi-pronged quality improvement efforts. Delays in recognition of serious events and appropriate escalation of care are associated with preventable maternal mortality based on interdisciplinary review. However, there is a limited understanding of the impact of diagnostic errors on maternal care. Mitigating diagnostic errors could be a key strategy for decreasing SMM/MM. In this session, we explored various strategies to apply a diagnostic safety lens to obstetric care and outlined tangible next steps to make progress in this emerging area.

Click here to view the resources Dr. Bajaj provided during her keynote.

Decrease Errors and Improve Patient Outcomes Through Simulation: Practicing for Obstetric Emergencies Without Putting Patients at Risk

Shad Deering, MD, CHSE, COL (ret) USA, Baylor College of Medicine

When emergencies happen during pregnancy, there are two lives at risk—every decision matters and can have lifelong consequences. Practicing with simulation can not only prepare teams for urgent situations but can also decrease errors related to missed diagnoses and identify facility issues that impact patient care. This type of training has been shown to improve maternal and fetal outcomes; we discussed both existing evidence and how it needs to be used moving forward as a part of comprehensive efforts to improve our care.

From Personal Experience to Professional Expertise: Using One Case of Maternal Morbidity to Inform Advocacy, Practice, and Research

Charity Watkins, PhD, Assistant Professor, Department of Social Work, North Carolina Central University

Using the case example of one Black woman who was diagnosed with peripartum cardiomyopathy two months postpartum, this presentation explored 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. Through one story of survivorship to scholarship, this presentation provided an example of how personal experience can inform professional expertise, including skills and knowledge gained from community advocacy, social work practice, and health equity research.

Attended live and looking for information about Continuing Education? Iowa Healthcare Collaborative will email information regarding continuing education (Continuing Medical Education, Nursing Continuing Education, and Certified Professional in Healthcare Quality – CPHQ) credits mid-April. If you have any questions in the interim, please reach out to Amber Rizzo, IHC Education Coordinator, at