Pennsylvania Patient Safety Advisory Diagnostic Error in Acute Care ABSTRACT or an Incident (i.e., a near miss or no harm event) are Errors related to missed or delayed diagnoses are submitted, it is not possible to quantify diagnostic a frequent cause of patient injury and, as such, are error in Pennsylvania with adverse event reports. Simi- an underlying cause of patient safety related events. larly, the Agency for Healthcare Research and Quality Autopsy series spanning several decades reveal (AHRQ) Common Formats—the common definitions error rates of 4.1% to 49.8%. Diagnostic errors are and reporting formats that allow healthcare provid- encountered in every specialty and are generally low- ers to collect and submit standardized information est, at less than 5%, for perceptual specialties (e.g., regarding patient safety events—does not include a radiology, pathology, dermatology) that rely heavily category specifically for diagnostic error (see http:// on visual pattern recognition and interpretation. Error www.pso.ahrq.gov/formats/commonfmt.htm). None- rates in other clinical specialties are higher, ranging theless, the Authority reviewed exactly 100 events from 10% to 15%, which is consistent with the added related to diagnostic error reported between June demands of data gathering and synthesis. Addition- 2004 and November 2009 in an effort to determine ally, diagnostic errors are frequently the leading or if there were system solutions to diagnostic error, or if second leading cause of malpractice claims in the diagnostic error was so intimately connected to physi- United States, accounting for twice as many alleged cians’ cognitive processing that system solutions were and settled claims as medication errors. Studies have not tenable. These events were found by searching shown that cognitive errors and system design flaws— on terms such as delayed diagnosis, wrong diagnosis, especially communication issues—all contribute to missed diagnosis, misdiagnosed, failure to diagnose, diagnostic error. This article reviews the common failure to treat, and medical follow-up. causes of diagnostic error, the clinical diagnoses most often affected by diagnostic errors, and risk reduction Statistics strategies that facilities, diagnosing physicians, and Errors related to missed or delayed diagnoses are a patients themselves can undertake to decrease diag- frequent cause of patient harm. In 2003, a systematic nostic error and increase patient safety. (Pa Patient Saf review of 53 autopsy studies from 1966 to 2002 was Advis 2010 Sep;7[3]:76-86.) undertaken to determine the rate at which autopsies detect important, clinically missed diagnoses. Diag- nostic error rates were 4.1% to 49.8% with a median During the last decade, much emphasis has been error rate of 23.5%.* Furthermore, approximately placed on system solutions to patient safety problems. 4% of these cases revealed lethal diagnostic errors Hospitals have focused on important issues to miti- for which a correct diagnosis coupled with treatment gate patient harm, including re-engineering systems, could have averted death.4 Other autopsy studies have improving the culture of safety, reducing communica- shown similar rates of missed diagnoses; one study tion barriers, and improving patient handoffs. How- reported the rate to be between 10% to 12%5, while ever, diagnostic error, despite being responsible for another placed it at 14%.6 Autopsies are considered twice as many adverse events as medication error,1 has the gold standard for definitive evidence of diagnostic received little attention. error, but they are being performed less frequently Diagnostic error is a diagnosis that is missed, incor- and provide only retrospective information. rect, or delayed, as detected by a subsequent definitive Diagnostic error is encountered in every specialty. test or finding.2 Not all misdiagnosis results in harm A 2008 review of diagnostic error studies showed a and harm may be due to either disease or interven- diagnostic error rate of less than 5% in the specialties tion. Misdiagnosis-related harm is preventable harm of pathology, dermatology, and radiology, all of which that results from the delay or failure to treat a condi- rely heavily on visual interpretation, and from 10% tion actually present when the working diagnosis was to 15% in most other fields, where data gathering either wrong or unknown or from treatment provided and synthesis play a much stronger role. The rate of for a condition not actually present. Misdiagnoses diagnostic error in the emergency department (ED) is represent a substantial unmeasured source of prevent- reported to be between 0.6% and 12%.7 able mortality, morbidity, and costs.3 However, it is not possible to focus on misdiagnosis-related harm without first understanding the broader issue of diag- * Of the 11 studies with error rates exceeding 30%, 5 involved nostic error. special populations (e.g., surgical patients, adult inpatients with AIDS, inpatients older than 85 years of age), and 5 were studies of The Pennsylvania Patient Safety Authority’s taxonomy general adult inpatients with overall autopsy rates lower than 31% (ranging from 12% to 100%), indicating, perhaps, that autopsies does not include a category for diagnostic error, and were performed primarily on cases with a higher level of suspicion because only those diagnostic errors associated with a for misdiagnosis to begin with. The remaining study was of medi- Serious Event (i.e., an event resulting in patient harm) cal patients with an autopsy rate of 47% and an error rate of 41%.4 Page 76 REPRINTED ARTICLE - ©2010 Pennsylvania Patient Safety Authority Vol. 7, No. 3—September 2010 Pennsylvania Patient Safety Advisory In the Harvard Medical Practice Study, physician definitive correct diagnosis, students were overconfi- errors resulting in adverse events were more likely to dent in 25% of the cases in which their confidence be diagnostic (14%) than drug-related (9%), and of and correctness were not aligned, residents were over- these adverse events, misdiagnoses (75%) were more confident in 41% of the cases, and faculty in 36% of likely to be considered negligent than others (53%).8 cases. These results show that even experienced physi- Diagnostic errors are also a leading cause of malprac- cians may be overconfident about the correctness of tice litigation, accounting for twice as many claims their diagnoses at the time that they make them.11 and settled cases as medication errors. In an analysis Overconfidence is a sign of miscalibration of one’s of 254 high-severity patient injury cases reported from diagnostic ability. Berner and Graber (2008) argue that January 2005 through July 2007, CRICO/RMF found even though physicians are well aware of the possibility that diagnostic error-related cases accounted for the of diagnostic error, few doctors are willing to admit to majority of the top five claims categories: diagnostic diagnostic error in their own practice. Graber reported error (44%), surgical (17%), medical (15%), obstetrics that only 1% of physicians with whom he had person- (11%), and medications (5%). The analysis also found ally spoken over a period of several years admitted to that these cases cost the company more than all other having made a diagnostic error in their own practice.7 categories combined—$127 million for diagnostic error Despite a global awareness of the problem of diagnos- versus $123 million for all other categories combined.1 tic error, physicians seldom believe that their own error In 2007, the Agency for Healthcare Research and rates are significant, further compounding the diffi- Quality (AHRQ) identified diagnostic error as an culty in analyzing diagnostic error.12 Given the dearth area of special emphasis. AHRQ found that diag- of feedback loops regarding diagnostic error, this is an nostic error comprised a substantial, costly portion understandable phenomenon; most physicians, in the of all medical errors and had resulted in distressing absence of concrete information that diagnoses are consequences for patients, families, and healthcare wrong, conclude that their diagnoses are correct. professionals. Furthermore, diagnostic error encom- An organization’s culture may encourage error col- passed a broad array of factors including cognitive lection and embrace error analysis—viewing errors as and systems (e.g., education, training, setting-of- learning opportunities—or it may ignore or hide them. care, disease-specific, domain-specific) issues.9 There are variations of culture along the continuum Subsequently, AHRQ sponsored research regarding between these points. Open recognition of diagnostic diagnostic error through the Diagnostic Error Evalua- error is one way to help physicians recalibrate their tion and Research (DEER) project. In 2009, research perception of diagnostic error and reduce overconfi- funded by this grant, in the form of analysis of physi- dence. Until there are mechanisms in place to collect cian reported errors (n = 583; convenience sample), and openly analyze diagnostic errors, calibration of revealed that 28% of the reported diagnostic errors true individual diagnostic error rates will be difficult were rated as major, resulting in patient death, perma- for physicians to achieve. nent disability, or a near-life-threatening event.10 Despite these statistics, diagnostic error remains an Diagnostic Decision Making underemphasized area of patient safety, being both Clinical judgment is an essential component of the difficult to detect and to dissect. Detection is diffi- diagnostic process in medicine. Cognitive psychol- cult for several reasons. First, misdiagnosed patients ogy literature has identified a dual-process model of who have not been harmed may never be known, as reasoning that has been used to analyze diagnostic there are few, if any, systems designed to detect and reasoning processes that occur in medicine.13,14 Two uncover benign diagnostic error. Second, even those systems form the basis of clinical decision making, patients who have been harmed through diagnostic System 1 (i.e., heuristic, intuitive) and System 2 (i.e., error might simply leave a practice, a physician, or a systematic, analytical).13 hospital and seek care elsewhere, hindering the ability to aggregate and study diagnostic error data. Finally, In System 1, the experience of the diagnosing physi- individual physicians may never know the true extent cian determines how well the information (e.g., patient of their own diagnostic error rates; feedback loops symptoms, history, physical examination findings) is regarding misdiagnoses are simply inadequate. It has interpreted.13 Physicians employ heuristics (i.e., cogni- been argued that the lack of these formal feedback tive or mental short cuts) to reach decisions, which are loops contributes to physician overconfidence in their correct in the majority of cases. This type of processing own diagnostic abilities.7,11,12 has been referred to as pattern-recognition processing.14 It happens quickly—almost reflexively. Patients present- Physician Confidence in Diagnostic Abilities ing with shortness of breath and pain in the jaw and left shoulder, for example, would easily fit into a recog- A prospective, counterbalanced experimental design nized pattern for “myocardial infarction.” Appropriate study found that even experienced physicians were tests would be ordered, and the physician would analyze unaware of the correctness of their diagnosis at the test results and diagnose the patient, who would then time the diagnosis was made. When 72 senior medical receive treatment quickly per known medical guidelines. students, 72 senior medical residents, and 72 faculty internists were given two- to four-page synopses of 36 System 2 typically occurs when the problem is not rec- diagnostically challenging medical cases, each with a ognized, or when the physician chooses to review the Vol. 7, No. 3—September 2010 REPRINTED ARTICLE - ©2010 Pennsylvania Patient Safety Authority Page 77 Pennsylvania Patient Safety Advisory case comprehensively for some reason.13 It employs disease presentation or patient-related factors, such hypothesis testing and deductive reasoning, is logically as uncooperative demeanor or deception. Systems- sound, and involves critical thinking. Medical stu- related factors contributed to diagnostic error in dents are taught System 2 decision-making processes 65% of the cases, cognitive factors contributed in early on, creating comprehensive lists of differential 74% of the cases, and in 46% of the cases, both diagnoses and analyzing each one for probability systems-related and cognitive factors contributed to and “fit.” In the real world, however, there is rarely diagnostic error. Overall, 228 system-related factors adequate time to use solely this method. Deliberate and 320 cognitive factors were identified, with an consideration and review (i.e., System 2) takes time, average of 5.9 factors per case.2 and the time pressures that exist in many clinical A 2007 analysis of 122 diagnostic errors in the ED settings may contribute to errors by causing an abbre- involved a random sample of closed malpractice viated or shortened clinical assessment. claims from four liability insurers alleging substan- In reality, physicians use a combination of both mod- dard diagnostic care in the ED. Breakdowns were els in the practice of medicine. While System 2 is common in the diagnostic steps that required active most similar to the scientific approach to medicine, it clinician decision making—specifically, conducting is rarely used first or alone. Physicians often practice patient medical histories and physical examinations, in suboptimal environments. They may be rushed, ordering and interpreting tests, ordering consulta- fatigued, distracted, or faced with severe resource con- tions, and creating follow-up plans. Such breakdowns straints. There may be an emotional reaction to the occurred in all but two of the missed diagnoses patient (e.g., positive, negative) or communication (97%). Failure to order appropriate tests was the issues that may subconsciously influence the cognitive most common breakdown, similar to Schiff’s find- processing of the physician. Therefore, while most phy- ings.10 After assimilation of the patient history and sicians undoubtedly would like to practice medicine in physical assessment, physicians must first generate an orderly, scientific, well-reasoned fashion similar to an appropriate diagnostic hypothesis, which then System 2’s analytical processing, the practice of medi- leads to test ordering. An inappropriate or incorrect cine occurs in situations that have many variables and diagnostic hypothesis will lead to incorrect or absent unknowns. The intuitive model of reasoning used in testing. Cognitive failure occurs when a physician has System 1 is an efficient and effective default method a correct diagnostic hypothesis but forgets or does not used by all physicians. However, when presented with know the correct work-up for that particular diagno- a challenging case, or one with perplexing characteris- sis. In summary, appropriate test ordering, like other tics, physicians can make a conscious choice to revert steps that involve active decision making, requires to the analytical approaches of System 2. these key ingredients: (1) assimilation of physical findings and generation of an appropriate diagnostic Regardless of the system or combination of systems used, hypothesis, (2) the availability of the right information diagnosis is a multistep process that requires listening, on which to base diagnostic decisions, and (3) correct collecting data regarding symptoms, performing focused application of cognitive skills to this information.16 examinations, ordering appropriate tests, synthesiz- ing data, and analyzing results, and there are plenty Commonly Misdiagnosed Conditions of opportunities for errors among these various steps. Schiff et al.10,15 developed and used the DEER taxonomy Commonly misdiagnosed conditions include cancer, to classify where errors were occurring in the diagnostic infection, fractures, myocardial infarction, embolism, processes (see “DEER Taxonomy Chart Audit Tool,” neurological conditions, and aneurysms. Table 1 one of several associated tools available from the Author- shows the top five misdiagnosed conditions from ity’s Web site at http://www.patientsafetyauthority.org/ several studies, three of which were derived from tort EducationalTools/PatientSafetyTools/Pages/home. claims, which biases the results toward more serious aspx). In the 2009 study, 583 errors that physicians (and—if missed—more costly) diagnoses. self-reported were analyzed. Most of the errors (44%) The top five categories of misdiagnoses from Author- occurred in the laboratory and radiology testing phase ity reports from January 2005 through August 2009 (e.g., failure to order, report, process, and follow up were metastatic cancer (12%), fractures (4%), pulmo- on test results); followed by clinician assessment errors nary embolism (4%), acute coronary syndrome (2%), (e.g., hypothesis generation, weighing and prioritizing, and appendicitis (2%). recognizing urgencies and complications) (32%); history taking (10%); physical examination (10%); and referral Common Causes of Diagnostic Error or consultation errors and delays (3%).10 Clinician assess- Cognitive Processing Errors ment errors were most closely linked to cognitive errors. Cognitive processing errors, or errors in thinking, Graber et al. (2005) analyzed 100 cases of diagnostic are linked to the heuristics frequently used in System error in internal medicine using a taxonomy that 1 (i.e., intuitive) mental processing. Some of the included no-fault, system-related, and cognitive fac- common heuristics employed during the diagnostic tors to clarify the basic etiology of diagnostic errors in process include the following:17,18 internal medicine and to develop a working taxonomy for diagnostic error.2 Seven of the 100 cases reflected ■ Representative heuristic is using “mental matching” solely no-fault errors, including masked or unusual to diagnose conditions with characteristic Page 78 REPRINTED ARTICLE - ©2010 Pennsylvania Patient Safety Authority Vol. 7, No. 3—September 2010 Pennsylvania Patient Safety Advisory Table 1. Commonly Misdiagnosed Conditions STUDY SETTING MISDIAGNOSIS PERCENTAGE (%) Gandhi TK, Kachalia A, Thomas EJ, et Ambulatory Cancer—all types 59% al. Missed and delayed diagnoses in the Infections 5 ambulatory setting: a study of closed mal- practice claims. Ann Intern Med 2006 Oct Fracture 4 3;145(7):488-96. Heart attack 4 (n = 181) Embolism 3 Schiff GD, Hasan O, Kim S, et al. Diagnostic General internists, medical Pulmonary embolism 4.5% error in medicine: analysis of 583 physician- specialists and emergency Drug reaction or overdose 4.5 reported errors. Arch Intern Med 2009 Nov physicians at 2 academic 9;169(20):1881-7. medical centers or within 20 Lung cancer 3.9 (n = 583) smaller teaching or community Colorectal cancer 3.3 hospitals Acute coronary syndrome 3.1 Kachalia A., Gandhi TK, Puopolo AL, et al. Emergency department Fracture 19% Missed and delayed diagnoses in the emer- Infection 15 gency department: a study of closed mal- practice claims from 4 liability insurers. Ann Myocardial infarction 10 Emerg Med 2007 Feb;49(2):196-205. Cancer 9 (n = 79) Cerebral vascular disease 8 Hanscom R. CRICO/RMF community targets 80/20 mix of outpatient care Cancer—all types 38% diagnostic error. CRICO/RMF Insight [online] and inpatient care Heart disease 8 2007 Sep [cited 2010 Feb 10]. Available from Internet: http://www.rmf.harvard.edu/ Cerebral vascular disease 5 education-interventions/crico-rmf-insight/ Arterial disease 4 archives/092007/art1.htm. (CRICO/RMF diagnosis related claims from Complications 4 2003 through 2007; n = 314) presentations that can predispose diagnosing phy- contributing factor in these reports. The 2007 sicians to a lack of differential diagnoses. review of closed malpractice claims in the ED16 ■ Availability heuristic is the tendency to accept a diag- found that the mean number of process breakdowns nosis due to ease in recalling a past similar event or and contributing factors per missed diagnosis was case, rather than based upon statistical prevalence two and three, respectively, clearly illustrating that or probability. compounding issues contribute to diagnostic errors. The 2005 review of diagnostic errors in internal Biases and limitations related to cognitive processing medicine identified an average of six contributing errors include the following:17,18 factors for each diagnostic error.2 ■ Anchoring is the tendency to stay with an original Communication Issues diagnosis despite evidence to the contrary. ■ Premature closure is narrowing the choice of diag- Poor or inadequate communication among clinicians nostic possibilities (i.e., hypotheses) too early in the and between clinicians and patients is frequently diagnostic process, such that the correct diagnosis cited as a contributing factor in diagnostic error.7,8,10,16 is never considered. Several facilities identified the contributing factor of “communication problems between providers” in ■ Satisficing is the acceptance of less than the ideal or events reported to the Authority. However, the event seeking a merely satisfactory solution, which is not narratives did not specify the exact communication necessarily the optimal one. problem, which prevents more in-depth analysis. For ■ Confirmation bias is the tendency to seek out data example, the following report was submitted as a fail- to confirm one’s original idea rather than to seek ure to diagnose and treat stroke with a contributing out or validate disconfirming data. factor of “communication problems between provid- ers” with root-cause analysis (RCA) in progress. ■ Context errors occur when the diagnosing physician is biased by patient history, previous diagnosis, The patient was admitted via the ED with com- or other factors and the case is formulated in the plaints of lower back pain postfall at home seven wrong context. days prior. The patient’s condition deteriorated with Table 2 shows a sampling of Authority reports with mental status changes, requiring urgent transfer to corresponding potential cognitive errors. the intensive care unit. RCA in progress. Cognitive errors may have contributed to the events Another report was submitted as a missed diagnosis in Table 2, some of which resulted in significant of acute coronary syndrome with contributing factors patient harm, but they are unlikely to be the sole of “communication issues between providers” and Vol. 7, No. 3—September 2010 REPRINTED ARTICLE - ©2010 Pennsylvania Patient Safety Authority Page 79 Pennsylvania Patient Safety Advisory Table 2. Sample Authority Event Reports with Possible Cognitive Errors POTENTIAL COGNITIVE EVENT REPORT PROCESSING ERROR1,2 POTENTIAL FAILURE(S) Patient is an infant seen in the ED [emergency Availability heuristic. The Authority report stated missed diagnosis department] during high flu season after an epi- tendency to accept a diagnosis of apnea and reflux. Physician poten- sode of vomiting and period of apnea observed based upon recent or vividly tially attributed symptoms to common by family. Was discharged, but returned later. recalled cases or events rather flu, due to availability. A more thorough Family reported that the patient had another than on prevalence or probability. physical examination may have led to episode of apnea. Patient was evaluated and the discovery of other symptoms indica- transferred to another facility for clinical impres- tive of apnea and reflux. sion of apnea and reflux. Patient seen in the ED on day one and day Anchoring heuristic. The Authority report stated missed diagnosis two for complaints of shortness of breath tendency to fixate on first of PE. Physician may have anchored on and chest pain. Diagnosed with an upper impressions or initial symptoms diagnosis “upper respiratory infection.” respiratory infection and sent home each time. without considering causes that Once a physician anchors on a diagno- Subsequently later admitted and died. Coroner appear later or those that do not sis, it is very difficult to introduce new preliminary report indicated PE [pulmonary support the initial hypothesis or differential diagnoses. Physician may not embolus] as cause of death. diagnosis. have considered alternate diagnoses on subsequent visits. Patient seen in ED on day one with complaints Premature closure. Acceptance Authority report stated missed diagnosis of abdominal pain. Patient evaluated, treated, of a diagnosis before it has of appendicitis. Physician omitted tests and discharged with diagnosis of UTI [urinary been fully vetted by considering that would have led to diagnosis of tract infection]. The next day, patient presented alternative diagnoses or searching ruptured appendix. Physician may have to another facility and was diagnosed with a for data that contradict the initial failed to consider differential diagnoses ruptured appendix. diagnosis. during history and physical portion of examination. Patient presented to the ED on day one with Anchoring heuristic. Authority report stated missed diagnosis complaints of chest pain. Stress test done, results Premature closure. of DVT. Physician may have anchored on negative, and patient discharged. The next Representative heuristic. Mental diagnosis “acute coronary syndrome” day, patient returned to the ED with chest pain matching to diagnose conditions due to complaints of chest pain. Physi- and tachypnea, and the left leg was blue and with characteristic presentations. cian may have latched on to representa- mottled. Dopplers of lower extremities confirmed Predisposes to lack of a differential tive symptom of chest pain, failing to extensive DVT [deep-vein thrombosis]. diagnosis. perform tests to rule out other potential diagnoses (i.e., differential diagnoses). A young man came to the ED for fainting and Premature closure. Authority report stated missed diagnosis syncope, including the inability to speak for a Context errors. Occur when the of brain lesion. Physician may have at- few seconds with lateralizing symptoms and diagnosing physician is biased by tributed symptoms to “stress” and evalu- staring. In the ED, lab work was done but no patient history, previous diagnosis, ated patient in this context. Physician CT [computed tomography] scan was ordered. or other factors and the case is may have failed to rule out other less Patient was discharged home with diagnosis of formulated in the wrong context. likely but more serious diagnoses. Physi- syncope and dehydration secondary to stress, cian may have formulated diagnosis in with instructions to follow up with primary the context of a young man with admit- care physician. Subsequently, the primary care ted stress and stopped searching for physician admitted the patient directly into the other plausible diagnoses for symptoms. hospital, where a CT scan was performed and a brain lesion diagnosed. Notes 1. Scott IA. Errors in clinical reasoning: causes and remedial strategies. BMJ 2009 Jun 8;338:b1860. 2. Groopman J. How doctors think. New York (NY): Houghton Mifflin Company; 2008. “lack of information due to dementia.” RCA was per- Even diagnostic events that do not result in harm can formed surrounding the physical assessment process. be traumatic for both the patient and the clinician, as the following example illustrates. Patient seen in ED; had been sent from SNF [skilled nursing facility] because he was moaning in discom- The physician entered the patient’s room and failed to fort. Patient had a history of dementia and was check the identification band. The physician did ask unable to relate what was wrong. Abdomen was the patient’s name and [then] started talking about a distended; enema had been given by SNF earlier in brain aneurysm and [relayed that the patient] would the day. Oxygen saturation level was 86% on room be going for surgery. The patient came to hospital with air. [The patient was] noted to have a urinary tract “leg pain.” The physician corrected the error later in infection, which was treated. He was discharged but the day [before the brain surgery occurred]. returned immediately. Upon return to the ED, he was bradycardic and then proceeded to full arrest. In a study involving diagnostic error in ambulatory Blood work was run on the specimens that were in settings, the diagnostic errors were complex and the lab from the initial visit and showed that the frequently involved multiple process breakdowns, con- troponin level was 20 [elevated; indicative of heart tributing factors, and clinicians. There was a median muscle damage; possible myocardial infarction]. of three process breakdowns and three contributing Page 80 REPRINTED ARTICLE - ©2010 Pennsylvania Patient Safety Authority Vol. 7, No. 3—September 2010 Pennsylvania Patient Safety Advisory factors per error.19 In a similar study involving diag- developed in conjunction with this article as a first step nostic error in internal medicine, an average of six in detecting diagnostic error (e.g., the “Deer Taxonomy different root causes were uncovered for each diagnos- Chart Audit Tool”), and by submitting event reports tic error event, two-thirds of which were considered with adequate information including the contributing system-related factors.2 factors and RCA information when performed. Other System-Related Factors Strategies to Decrease Diagnostic Errors The fact that cognitive errors rarely are the sole cause System-Level Strategies of diagnostic error points toward the possibility of system-level interventions to decrease recurrence of Changing the perception of diagnostic error from diagnostic errors and to mitigate harm from them “errors in judgment,” “errors in thinking,” or when they do occur.16,20 Common system-related “physician mistakes” to errors related to cognitive factors that contribute to diagnostic error include processing, communication, and system design may those related to specimen identification, test tracking, be the first step toward recognizing and reducing reporting of abnormal and critical test results, and diagnostic error.3 Finding and reporting misdiagnosis- transitions in care. Diagnostic error reports from the related patient harm is the second step, although it Authority’s database illustrate how some of these may be hard to achieve. When the U.S. Department system-related factors contribute to diagnostic error. of Health and Human Services Office of the Inspec- tor General investigated methods for identifying Specimen Labeling adverse events in hospitals (case study; random sam- The patient underwent a needle biopsy of the right ple of 278 Medicare beneficiary hospitalizations), it breast that was diagnosed as ductal carcinoma. found that hospitals did not provide, and apparently Patient then underwent lumpectomy of right breast, did not have, event reports for 93% of the events (n = and [another] pathologist questioned the results 120).21 This study analyzed all adverse events, not just postprocedure after reviewing the tissue. The hospital those related specifically to diagnostic error (which is was notified about the potential wrong diagnosis . . . more elusive and even more difficult to detect). unable to determine how the specimen was mislabeled. Healthcare facilities may consider the following strat- Communication of Critical Pathology Reports egies in an effort to increase the detection rate of The patient underwent a transthoracic biopsy of a diagnostic error in their facilities: lung nodule. The pathology result noting cancer was ■ Provide a mechanism to collect diagnostic error discovered [more than six months later]. reports within the facility (see the “Deer Taxonomy Abnormal Test Results Chart Audit Tool”). Collection and aggregation of diagnostic error data allows for tracking, trending, The patient described slipping when coming out of uncovering patterns, learning across cases, and her kitchen; the patient fell on her right side. X-rays measuring improvement.10,15 were done, and the preliminary report was negative according to the surgeon. The final report revealed a ■ Continuously improve the culture of safety so that femoral neck fracture, which was available but not identification and analysis of diagnostic error is seen by the physician [for nearly 15 days]. acceptable and anticipated.15,20 Include diagnostic error as a key part of the quality assurance plan. Poorly Managed Transition in Care Identify any diagnostic-related adverse events and An elderly woman presented to the ED in month one incidents that appear repeatedly as possible “nor- with chest pain and shortness of breath. A chest CT malization of deviance,” and intervene as needed.20 [computed tomography scan] identified multiple emboli ■ Conduct analysis of events that result in misdi- and a lung nodule suspicious for carcinoma. The agnosis-related patient harm. Consider a tool patient underwent a cardiac catheterization and was similar to the one used in Graber’s 2005 analysis discharged from the hospital with no documented medi- of diagnostic error,2 which helps practitioners not cal follow-up for the lung nodule. The patient returned only identify categories of diagnostic error but also to the ED in month six with shoulder pain. A CXR provides underlying causes for the failures. [chest radiograph] was performed, and the patient was discharged with instructions to follow up with her phy- Event analysis in the medical literature shows that sician for a chest CT in regard to the lung nodule. The most diagnostic-related errors have multiple causes, patient was admitted to the hospital in month seven and even cognitive aspects of diagnostic error can and has been diagnosed with carcinoma . . . be mitigated by interventions at the system level.16,20 Healthcare facilities may consider the following system- Focusing attention on system-related factors level strategies to reduce misdiagnosis-related harm: underlying issues related to specimen labeling, com- munication of reports, abnormal test results and ■ Strategies to combat cognitive errors include the transitions in care (e.g., work overload, inadequate following: staffing, unavailable resources) is one way to identify — Provide information about and encourage and reduce diagnostic errors in acute care settings. the general study of clinical and pathologi- Healthcare facilities can help the Authority with cal discrepancies to learn about all types of analysis of diagnostic error events by using the tools diagnostic error.15,17 Study and test diagnostic Vol. 7, No. 3—September 2010 REPRINTED ARTICLE - ©2010 Pennsylvania Patient Safety Authority Page 81 Pennsylvania Patient Safety Advisory accuracy on standardized cases similar to ■ Systems strategies to enhance communication and Johns Hopkins University School of Medicine coordination of care include the following: Clinico-Pathological Conferences (http:// — Migrate toward electronic medical records to oac.med.jhmi.edu/CPC/) or AHRQ’s Web ensure that patient information is available to M&M: Morbidity and Mortality Rounds on all care providers in real time, in all settings. the Web (http://www.webmm.ahrq.gov/ index.aspx). Develop formal policies regarding the commu- nication of patient information across all care — Provide resources for clinical decision support settings.20 Integrate automatic reminders for systems that provide accurate estimates of reporting test results to patients and schedul- disease probability. DXplain (http://dxplain. ing follow-up.3,7 org/dxp/dxp.pl ) and Isabel (http://www. isabelhealthcare.com/home/default) are two — Ensure an efficient and effective system of Web-based applications that help physicians communicating abnormal and critical test make data-driven diagnostic decisions at the result procedures directly to the ordering point of care. Do not rely solely on physician physician and the patient. Monitor the turn- perception of diagnostic accuracy as a measure around time of key tests.10,12,16,20,22 of need; research shows that even experienced — Ensure that specialty expertise is available physicians may be overconfident about the when needed, at all times and on all days. correctness of their diagnoses when they make Monitor consultation timeliness.7,12,20,22 them.11 Provide point-of-care access to the Internet, electronic medical references, and — Consider mandatory second opinions on key journals.3,7,10,12,16,17,20,22 error-prone diagnoses and second readings of — Provide access to computer-assisted feature key diagnostic tests.12,16,22 mapping and/or data visualization tools to — Ensure that there is a standardized process for enhance the accuracy of diagnostic decision handoff procedures between physicians and making.3,12,20 across care units.16 — Provide resources and encourage the use of — Provide close oversight of trainees’ diagnostic clinical guidelines and clinical algorithms. evaluations especially in cases of high work- When well-designed, these resources remedy load or with complex patients or with patients the deficiencies in human judgment by incor- with atypical presentation. Provide a mecha- porating statistics, epidemiology, and decision nism for supervisory oversight of diagnostic theory in a clinically useful format.16,22 decision-making strategies.16 — Consider diagnostic checklists to prevent reli- — Ensure strong mechanism for follow-up of ance on memory for error-prone processes discharged patients, especially for high-risk (e.g., soliciting a complete history, perform- diagnoses or symptoms for which a diagnosis ing a targeted physical examination, ordering has not yet been assigned (e.g., cancer: rule appropriate tests). These can be organized around high-risk diagnoses (e.g., cancer, out cancer; myocardial infarction: chest pain infection, fractures, myocardial infarction) and shortness of breath).15 or around care settings (e.g., routine wellness ■ Other system-related factors: visit checklist that reminds about screening — Establish pathways for physicians who saw the protocols, sick visit checklist that lists “don’t patient earlier to learn if or when a diagnosis miss” diagnoses).3,10,15 A general checklist designed to minimize diagnostic error has is changed by developing audit protocols been previously published23 and is available as to uncover diagnostic error, comparing ED a pocket card at the Authority’s Web site (see diagnoses to discharge diagnoses, auditing “A Checklist for Diagnosis”). diagnoses of patients who return to the ED within 48 hours after discharge and making — Enhance feedback to clinicians regarding note of diagnoses that change from one visit diagnoses and errors to increase calibration to the next, performing retrospective chart and reduce overconfidence regarding their audits to look for changed diagnoses during own diagnostic error rate. Improving feed- the course of a hospitalization, comparing back to clinical practitioners may be the most consulting/referral diagnoses to referring effective debiasing procedure available. This physician diagnoses by tracking radiology and can be accomplished, in part, by means of pathology over-reads and by tracking changes postmortem autopsies and/or postmortem to initial laboratory test results (see the online magnetic resonance imaging, morbidity and “Diagnostic Error Measures Worksheet”). mortality conferences, sentinel event analysis, or retrospective audits of admitting versus — Develop a mechanism to share the results of discharge diagnoses or of diagnoses of patients these types of audits with all treating physi- who return to the ED within 48 hours of cians in a timely fashion. Soliciting feedback discharge.7,12,17,20 from practitioners regarding diagnostic error Page 82 REPRINTED ARTICLE - ©2010 Pennsylvania Patient Safety Authority Vol. 7, No. 3—September 2010 Pennsylvania Patient Safety Advisory is a critical step in the learning process.15,20 In about diagnostic probabilities and uncertainties to addition to learning when diagnostic error minimize disappointments and surprises and to sup- occurs, it is equally important to investigate port and enhance patient initiative in questioning the causes, and this cannot be done without frank diagnostic process and outcome. (For more informa- conversations with physicians about why these tion, see the online “Patient Education Regarding errors occurred. Diagnostic Error”). — Guard against excessive workload and staff Conclusion fatigue. Minimize disruptions and production pressures so that diagnosing physicians have Despite the fact that the diagnostic process has many time to reflect on their diagnostic decisions. steps, is frequently shared between multiple providers Minimize errors related to fatigue by imple- and sometimes across multiple settings, and occurs over menting work hour limitations and allowing a period of months or even years, healthcare facilities naps, if needed.16,20 have at their disposal many strategies that could poten- tially reduce the diagnostic error rate. Implementing Physician Strategies interventions that establish strong and reliable feed- Physicians themselves play an important role in back loops between and among physicians regarding the detection and prevention of diagnostic error. diagnostic accuracy is a key step in the error-reduction Individuals may consider the following strategies to process. Ensuring that all steps in the diagnostic testing reduce diagnostic error in their practice: phase occur correctly and that all results are com- ■ Improve clinical reasoning and metacognition municated back to ordering physicians and patients skills by learning about cognitive errors.17,20 is critically important, as are methods to enhance the effectiveness of diagnostic decision making. ■ Use diagnostic time-outs to actively reflect upon the diagnostic process.17,20 In addition to system-level interventions, physicians themselves must actively work toward first ■ Request second opinions and consultations as recognizing, then analyzing, and finally reducing needed.17,20 diagnostic error. Acknowledging the lack of feedback ■ Request diagnostic feedback from healthcare facili- mechanisms in healthcare facilities and seeking out ties and colleagues to improve calibration regarding ways to give and receive collegial diagnostic feedback diagnostic error.12,17,20 is an important first step. Accepting the possibility ■ For specialists who modify diagnoses of referral of diagnostic error is also important; acceptance of a patients, notify the referring physician of the modi- less than perfect diagnostic record may lead to greater fied or changed diagnosis.17 metacognition and recognition of diagnostic error when it does occur. Likewise, mentoring residents by ■ Disclose the diagnosis to the patient early. Disclose actively discussing diagnostic challenges, diagnostic the probability of having the diagnosis, and what decisions, and even diagnostic failures will help to expect if the diagnosis is correct. If there is no new physicians develop a more accurate perception clear diagnosis, disclose this, too.20 of their diagnostic abilities and skills. Universities ■ Maintain long-term continuity of care with indi- and teaching hospitals also have a role to play: by vidual patients to ensure adequate awareness of illuminating the topic of diagnostic error early in past mistakes. Survey past patients, and investigate each medical student’s education, in both didactic whether diagnostic error occurred. and practical learning settings, there is the potential to reduce physician overconfidence and to correct ■ Mentor residents and medical students by openly dis- individual calibration of diagnostic error. Allowing cussing diagnostic thinking patterns, soliciting their medical students and residents to openly question diagnostic reasoning, and providing timely and criti- diagnostic decisions, verbalize their own diagnostic cal feedback regarding their diagnostic processes.17,18 reasoning, and receive specific constructive feedback A review of some of the cognitive errors presented in a timely fashion are important steps toward earlier shows that even cognitive errors are amenable enhanced diagnostic accuracy. to both individual and system-level interventions Involving patients in the diagnostic process may listed above (Table 3). help reduce diagnostic error. By encouraging and Using a combination of individual and system-level empowering patients to give and receive information risk reduction strategies may help decrease both the with their physicians, to question any step in the diagnostic error rate and the rate of misdiagnosis- diagnostic process, and to report changes in their related patient harm in healthcare facilities. condition or results of second opinions to their Patient Education Strategies physicians, providers can enable patients to become Patients can participate in the effort to reduce diag- important partners in the diagnostic process. nostic errors. Facilities can endeavor to educate and The Authority encourages each healthcare facility empower patients to seek timely follow-up care and to begin monitoring diagnostic error rates. Once medical advice and to become active participants in facilities begin collecting data regarding diagnostic the diagnostic process. For example, educate patients error, the Authority invites use of the sample Vol. 7, No. 3—September 2010 REPRINTED ARTICLE - ©2010 Pennsylvania Patient Safety Authority Page 83 Pennsylvania Patient Safety Advisory Table 3. Sample Authority Event Reports with Associated Individual and System Error Mitigation Strategies POTENTIAL COGNITIVE POTENTIAL PROCESSING INDIVIDUAL EVENT REPORT FAILURE(S) ERROR1,2 STRATEGY SYSTEM STRATEGY Patient is an infant seen Authority report stated Availability heuristic. Use checklists for physi- Provide decision support in the ED [emergency missed diagnosis of The tendency to cal examination com- systems to diagnos- department] during apnea and reflux. accept a diagnosis ponents. Use decision ing physicians. Provide high flu season after Admitted during high based upon recent or support resources, if point-of-care clinical an episode of vomiting flu season; potentially vividly recalled cases available. Confer with resources such as elec- and period of apnea attributed symptoms or events rather than colleagues, and seek tronic medical records, observed by family. Was to common flu, due on prevalence or out second opinions. Internet access, and ac- discharged, but returned to availability. A more probability. cess to electronic medi- later. Family reported thorough physical cal journals and pre- that the patient had an- examination may have scribing data. Encour- other episode of apnea. led to the discovery age the use of diagnos- Patient was evaluated of other symptoms tic checklists to improve and transferred to an- indicative of reflux. systematic examinations other facility for clinical and to decrease reliance impression of apnea on memory. and reflux. Patient seen in the ED on Authority report stated Anchoring heuristic. Think beyond the most Implement a system to day one and day two for missed diagnosis of The tendency to fixate obvious diagnosis. automatically screen complaints of shortness PE. Anchored on diag- on first impressions Perform comprehensive patients returning to the of breath and chest nosis “upper respira- or initial symptoms and systematic physical ED within 48 hours. Pro- pain. Diagnosed with tory infection.” Once a without considering examinations. Use a vide decision-support an upper respiratory physician anchors on causes that appear diagnostic time-out information in the form infection and sent home a diagnosis, it is very later or those that do and reflective thinking of clinical algorithms each time. Subsequently difficult to introduce not support the initial about the patient and based upon evidence- later admitted and died. new differential diag- hypothesis or diagnosis symptoms in a calm based medicine. En- Coroner preliminary noses. May not have environment. Consider sure the availability of report indicated PE considered alternate worst-case scenarios. specialty consultations [pulmonary embolus] as diagnoses on subse- Ask, “What do I not 7 days per week, 24 cause of death. quent visits. want to miss?” hours per day. Encour- age physicians to seek out second opinions on high-risk populations (e.g., return to the ED within 48 hours). Notes 1. Scott IA. Errors in clinical reasoning: causes and remedial strategies. BMJ 2009 Jun 8;338:b1860. 2. Groopman J. How doctors think. New York (NY): Houghton Mifflin Company; 2008. “DEER Taxonomy Chart Audit Tool,” to trend diag- errors over time: a systematic review. JAMA 2003 Jun nostic error reports, to identify where in the diagnostic 4;289(21):2849-56. process errors occur, to analyze aggregate results, and 5. Goldman L, Sayson R, Robbins S, et al. The value of to develop and implement both physician- and system- autopsy in three medical eras. N Eng J Med 1983 Apr level strategies to reduce diagnostic error occurrence. 28;308(17):1000-5. Notes 6. Sonderegger-Iseli K, Burger S, Muntwyler J, et al. 1. Hanscom R. CRICO/RMF community targets diagnos- Diagnostic errors in three medical eras: a necroscopy tic error. CRICO/RMF Insight [online] 2007 Sep [cited study. Lancet 2000 Jun 10;355(9220):2027-31. 2010 Feb 10]. Available from Internet: http://www.rmf. 7. Berner ES, Graber ML. Overconfidence as a cause of harvard.edu/education-interventions/crico-rmf-insight/ diagnostic error in medicine. Am J Med 2008 May;121(5 archives/092007/art1.htm. Suppl):S2-S23. 2. Graber ML, Franklin N, Gordon R. Diagnostic 8. Leape LL, Brennan TA, Laird N, et al. The nature of error in internal medicine. Arch Intern Med 2005 Jul adverse events in hospitalized patients. Results of the 11;165(13):1493-9. Harvard medical practice study II. N Eng J Med 1991 Feb 3. Newman-Toker DE, Provonost PJ. Diagnostic errors— 7;324(6):377-84. the next frontier for patient safety. JAMA 2009 Mar 9. Agency for Healthcare Research and Quality (AHRQ). 11;301(10):1060-2. Special emphasis notice (SEN): AHRQ announces 4. Shojania KG, Burton EC, McDonald KM, et al. interest in research on diagnostic errors in ambulatory Changes in rates of autopsy-detected diagnostic care settings [notice NOT-HS-08-002 online]. 2007 Page 84 REPRINTED ARTICLE - ©2010 Pennsylvania Patient Safety Authority Vol. 7, No. 3—September 2010 Pennsylvania Patient Safety Advisory Oct 25 [cited 2010 Mar 17]. Available from Internet: 16. Kachalia A., Gandhi TK, Puopolo AL, et al. Missed and http://grants.nih.gov/grants/guide/notice-files/ delayed diagnoses in the emergency department: a study NOT-HS-08-002.html. of closed malpractice claims from 4 liability insurers. Ann Emerg Med 2007 Feb;49(2):196-205. 10. Schiff GD, Hasan O, Kim S, et al. Diagnostic error in medicine: analysis of 583 physician-reported errors. Arch 17. Scott IA. Errors in clinical reasoning: causes and Intern Med 2009 Nov 9;169(20):1881-7. remedial strategies. BMJ 2009 Jun 8;338:b1860. 11. Friedman CP, Gatti GG, Franz TM, et al. Do physicians 18. Groopman J. How doctors think. New York (NY): know when their diagnoses are correct? Implications for Houghton Mifflin Company; 2008. decision support and error reduction. J Gen Intern Med 19. Gandhi TK, Kachalia A, Thomas EJ, et al. Missed and 2005 Apr;20(4):334-9. delayed diagnoses in the ambulatory setting: a study of 12. Graber M. Diagnostic errors in medicine: a case of closed malpractice claims. Ann Intern Med 2006;145:488-96. neglect. Jt Comm J Qual Patient Saf 2005 Feb;31(2):106-13. 20. Graber ML. Taking steps toward a safer future: measures 13. Croskerry P. A universal model of diagnostic reasoning. to promote timely and accurate medical diagnosis. Am J Acad Med 2009 Aug;84(8):1022-8. Med 2008 May;121(5 Suppl):S43-6. 14. Schwartz A, Elstein AS. Clinical reasoning in medicine. 21. U.S. Department of Health and Human Services, Office of the Inspector General. Adverse events in hospitals: In: Higgs J, Jones M, Loftus S, et al, eds. Clinical methods for identifying events [executive summary online]. reasoning in the health professions. 3rd ed. Boston (MA): 2010 Mar [cited 2010 Mar 8]. Available from Internet: Elsevier; 2008:223-34. ? http://oig.hhs.gov/oei/reports/oei-06-08-00221.pdf. 15. Schiff GD, Kim S, Abrams R, et al. Diagnosing diagnos- 22. Elstein AS. Thinking about diagnostic thinking: a tic error: lessons from a multi-institutional collaborative 30-year perspective. Adv in Health Sci Educ. 2009;14:7-18. project. In: Henriksen K, Battles JB, Marks ES, et al., eds. Advances in patient safety: from research to implementa- 23. Graber ML. Educational strategies to reduce diagnostic tion. Rockville (MD): Agency for Healthcare Research error: can you teach this stuff? Adv Health Sci Educ and Quality; AHRQ pub No. 05-0021-2. 2005:255-78. 2009;14:63-9. ? Self-Assessment Questions The following questions about this article may be useful for inter- nal education and assessment. You may use the following examples 1. During the first ED visit, which factor most likely contrib- uted to the attending physician’s incorrect diagnosis of or come up with your own. gastroenteritis? A 35-year-old man with no significant past medical history a. Atypical presentation: lack of classic physical signs went to the emergency department (ED) complaining of of appendicitis. vomiting and periumbilical abdominal pain for four hours. b. Lack of awareness: abdominal pain is an uncommon On physical examination, he was afebrile, with a blood chief complaint in the ED. pressure of 114/72 and a heart rate of 85. His abdomen was soft, without rebound or guarding. He was diagnosed c. Availability heuristic: accepting a diagnosis (gastroen- with gastroenteritis and discharged with antiemetics and teritis) due to ease in recalling past similar cases. instructions to return to the ED for persistent vomiting, d. Premature closure: settling on a diagnosis before ruling pain, or new fever. The patient presented to his primary out other possibilities. care physician’s office three days later with complaints of persistent abdominal pain; the vomiting had resolved. 2. During the visit with the primary care physician three days The primary physician contacted ED personnel to obtain later, which event most likely contributed to the continued the report. On examination, the patient was afebrile with diagnostic error? normal vital signs. He had a diffusely tender abdomen with a. Lack of communication between the primary care some localization to the right of the umbilicus. The patient physician and the ED personnel regarding the patient’s was sent home, with instructions to take over-the-counter medication for the pain. The next day, the patient returned medical history. to the ED with persistent pain. He was seen by the same b. The primary care physician failed to perform a ED attending physician, who asked a colleague to evaluate thorough physical assessment of the patient. the case. The second ED attending physician ordered a c. Anchoring bias: the primary care physician relied too computed tomography (CT) scan of the abdomen and heavily on the previous medical report when formulat- pelvis. The CT scan revealed a perforated appendix.* ing his own medical conclusions and stayed with the original diagnosis despite evidence to the contrary. * Adapted from: Agency for Healthcare Research and Quality (AHRQ). Missed appendicitis. AHRQ M&M on the Web 2003 d. The patient was not compliant with the ED discharge Jun [cited 2010 Jul14]. Available from Internet: http://www. instructions, further hindering the diagnosis of webmm.ahrq.gov/case.aspx?caseID=17&searchStr=appendicitis. appendicitis. Vol. 7, No. 3—September 2010 REPRINTED ARTICLE - ©2010 Pennsylvania Patient Safety Authority Page 85 Pennsylvania Patient Safety Advisory 3. Representative heuristic is the: A woman presented with multiple breast lumps in her a. tendency to formulate a diagnosis with information left breast. A biopsy of the dominant lump was diagnosed obtained from a second party. as Stage I breast cancer. She underwent lumpectomy, b. tendency to accept a diagnosis based upon the ease which removed all lumps but one. She saw several physi- of recall of past similar cases rather than based upon cians over the next two years, and although the lump was statistical prevalence or probability. recorded in her medical chart, no physician ever followed up with her about it. Over this period, the breast cancer c. use of cognitive shortcuts to formulate a list of diagnos- developed from a treatable Stage I to Stage III, and it tic probabilities representative of the chief complaint. metastasized to her brain. d. use of “mental matching” to diagnose conditions with characteristic presentations. 6. The above case illustrates principles similar to findings in the literature regarding diagnostic error. Which statement 4. The most effective strategy for physicians to evaluate below most accurately describes the etiology of many diagnostic decisions and minimize cognitive errors is to: diagnostic errors? a. always get a second opinion on appendectomy cases. a. Individual, one-time errors in judgment account for b. take a diagnostic time-out to think broadly about the the majority of diagnostic errors. case; metacognition. b. Patient-related factors account for most instances of c. use diagnostic testing to rule out false-negative diagnostic error-related patient harm. presentations. c. Diagnostic errors that reach patients appear to result d. ask a patient to relay all pertinent information before from the alignment of multiple breakdowns, which in beginning the physical examination. turn stem from a confluence of contributing factors. A woman had a pigmented lesion on her leg biopsied d. Diagnostic errors can usually be traced to a single, by her physician in the hospital and sent to the lab and discrete probable cause, which can be resolved through a pathologist for review. The pathologist correctly deter- staff education and training. mined that the lesion was a melanoma. However, the lab sent the report of another patient (labeled with a different 7. Which facility-level strategy is most likely to increase patient name) back to the woman’s physician, reporting detection of diagnostic error? that the lesion was benign. The physician did not notice a. Ensure a culture of safety exists so that the detection the wrong name on the report. The lab realized its mistake and analysis of diagnostic error is acceptable; provide eight months later, and notified the physician who told the a mechanism to collect diagnostic error data; and patient. As a result, the patient’s melanoma spread to her conduct analysis of collected events. groin nodes, and it required more extensive treatment than b. Purchase an error-collection system for frontline if the diagnosis been timely. reporting; implement mandatory reporting of 5. Which system-level intervention could the facility implement diagnostic error; and enforce compliance through to best prevent the type of diagnostic error illustrated above? vigilant auditing of medical records. a. Install a diagnostic decision support software system. c. Increase autopsy rates within the facility; track b. Implement a system of authentication of all abnormal misdiagnosis-related patient harm by provider; and test results, verifying critical patient information. create and publicize comparison reports of harm by c. Implement a multisystem electronic medical record so provider. that medical information is available across care settings. d. Purchase diagnostic decision-support software; d. Educate physicians and staff regarding the importance implement mandatory reporting of diagnostic error; of filing test results in the appropriate medical records. and train physicians in metacognition. Page 86 REPRINTED ARTICLE - ©2010 Pennsylvania Patient Safety Authority Vol. 7, No. 3—September 2010 PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 7, No. 3—September 2010. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2010 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. This publication is disseminated via e-mail. To subscribe, go to http://visitor.constantcontact.com/ d.jsp?m=1103390819542&p=oi. To see other articles or issues of the Advisory, visit our Web site at http://www.patientsafetyauthority.org. Click on “Patient Safety Advisories” in the left-hand menu bar. THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS The Pennsylvania Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (“Mcare”) Act. Consistent with Act 13, ECRI Institute, as contractor for the Authority, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the Pennsylvania Patient Safety Authority, see the Authority’s Web An Independent Agency of the Commonwealth of Pennsylvania site at http://www.patientsafetyauthority.org. ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for nearly 40 years, ECRI Institute marries experience and independence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology. The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP’s efforts are built on a nonpunitive approach and systems-based solutions.