New Checklist Offers Roadmap for Improved Diagnostic Performance
Emergency clinicians spend much time making diagnoses, but knowing they are right is another matter. The Society to Improve Diagnosis in Medicine reports missed or delayed diagnoses are a major public health problem, leading to higher costs, malpractice claims, and potentially adverse outcomes for patients.1
To help, researchers created the Safer Dx Checklist, a new roadmap for medical practices committed to improving diagnostic performance.2 Although the tool is not specifically designed for EDs, Prashant Mahajan, MD, MPH, MBA, and colleagues helped make the tool more applicable to that environment. He says the emergency setting is different from other healthcare areas in a few unique ways that are pertinent to the diagnostic process.
“When patients come into the ED, we have not established a prior relationship with them like the patients might have with their family care provider. Also, there are many interruptions with other cases ... all of this makes the ED a ripe environment that predisposes us to make errors.” observes Mahajan, vice chair for the department of emergency medicine at the University of Michigan.
Mahajan adds emergency physicians care for some patients who cannot communicate well because of their age or their medical condition. Often, the illnesses that cause patients to visit the ED have not yet evolved, making it difficult to formulate the right diagnosis.
“For example, for a patient to have pneumonia, you need to have fever, cough, and difficulty breathing, so then you start looking for pneumonia,” says Mahajan, chief of children’s emergency services at CS Mott Children’s Hospital in Ann Arbor, MI.
However, if the illness is early onset, the clinician may observe only a fever and slight cough. Mahajan and colleagues made sure such factors were considered as the Safer Dx Checklist was developed. The resulting instrument includes 10 high-priority practices the authors maintain are key to promoting diagnostic excellence.
The first practice calls for establishing an accountability framework that includes the structure and resources needed to identify opportunities for diagnostic improvement and to regularly monitor progress. The second practice emphasizes the need to promote a just culture where clinicians can report diagnostic errors or opportunities without worrying about any repercussions.
Mahajan notes there could be many contributing factors to diagnostic errors, so context is important. For instance, a patient may not have reported an important symptom, the ED may have been inundated with patients at the time of the diagnosis, or there may be system problems that led to a faulty or delayed lab result. “We have to look at diagnosis with a multipronged view, but also with a non-punitive view,” Mahajan says.
The third practice calls for the creation of feedback loops so clinicians can connect their diagnosis and treatment decisions with patient outcomes. This is difficult in the ED, but Mahajan stresses the EMR can be leveraged to report information on select patients to the treating providers.
For examples, leaders might want to focus on reviewing the cases of patients who made a return trip to the ED and were admitted. With some help from IT, the EMR might be programmed to provide feedback to the treating clinicians on these specific patients.
To ensure all factors are considered in the case of a missed diagnosis, item the fourth practice calls on organizations to include multidisciplinary perspectives when reviewing a diagnostic safety event. Developers note this should include human factors perspectives as well as consideration of IT system design and cognitive factors.
Item five notes there should be a mechanism for retrieving patient and family feedback on diagnostic errors, while the sixth priority calls for healthcare organizations to encourage patients to review their medical records, and to provide support to help them understand diagnostic-related information.
The seventh practice indicates equity must be prioritized to ensure any observed gaps in diagnostic performance or safety efforts are not more pronounced in certain populations. The eighth item calls for standardized processes for treating clinicians to collaborate with diagnostic specialists, such as the lab, pathology, and radiology, when there are diagnostic challenges.
Communication is emphasized in the final two items. Specifically, developers encourage organizations to establish standard processes so diagnostic information is reliably relayed to patients, families, and clinicians. The authors also stress the need for systems to ensure there is appropriate communication and follow-up on both abnormal test results and referrals.
Mahajan acknowledges that for most hospitals and EDs, it will take time to put the kind of accountability framework in place the developers of the Safer Dx Checklist have in mind. In fact, he notes the University of Michigan is in the process of building such a framework.
“For many years, the whole issue of patient safety was focused on things like wrong site [surgery] and wrong medications, but now there is this trend toward looking at [diagnostic] issues, too, which has been a blind spot,” Mahajan says.
REFERENCES
- Society to Improve Diagnosis in Medicine. What is diagnostic error?
- Baylor College of Medicine. The Safer Dx Checklist: 10 high-priority organizational practices for diagnostic excellence. March 2022.