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Publication Type: Patient Safety Advisory
Single or Multiple Incident: Multiple
Date: 10/31/2018 12:00:00 AM
This covering page from a special issue of the Pennsylvania Patient Safety Advisory provides articles which offer a glimpse into the depth, breadth, and complexity of the diagnostic process. From a discussion with subject matter experts about how to define the term diagnostic error to an analysis reflecting all potential failure points along the continuum of the diagnostic process, the content illustrates how some aspect of diagnosis is involved in nearly every healthcare encounter. The excerpt provides highlights of risk mitigating strategies to improve diagnosis.


Communication
  1. Acknowledge that some patients still believe that "no news is good news" when it comes to their test results. Engage patients as members of the diagnostic team, educate them about their roles, and empower them to follow up with you if they do not receive their results.
  2. Recognize the importance of gathering and communicating information related to suicide risk assessment. Assess your processes for collecting complete information from patients and ensuring thorough communication between providers. Improvements in these two areas are crucial for a more accurate and timely diagnostic process for this vulnerable patient population.
Rules / Policies / Procedures
  1. Use the modified DEER taxonomy to classify failures in the diagnostic process using existing sources of data, such as incident reports, patient complaints, quality reviews, and malpractice claims. Identify patterns of failure to focus on and prioritize aspects of the process for learning and improvement.
  2. Understand that while health information technology (health IT) can improve efficiency and reduce the risk of error, it can also contribute to problems in processes such as laboratory testing. Engage a multidisciplinary team of experts to identify and correct potential health IT-related hazards in your laboratory testing processes.
  3. Review processes for communicating incidental radiology findings among providers and with patients to ensure that recommended testing and treatment are pursued in a timely fashion. Incidental findings can be a source of significant patient harm or death if missed or not communicated properly.

Improving Diagnosis: Action and Insights