Improving Diagnostic Fidelity

Abstract

Objective To reliably improve diagnostic fidelity and identify delays using a standardized approach applied to the electronic medical records of patients with emerging critical illness. Patients and Methods This retrospective observational study at Mayo Clinic, Rochester, Minnesota, conducted June 1, 2016, to June 30, 2017, used a standard operating procedure applied to electronic medical records to identify variations in diagnostic fidelity and/or delay in adult patients with a rapid response team evaluation, at risk for critical illness. Multivariate logistic regression analysis identified predictors and compared outcomes for those with and without varying diagnostic fidelity and/or delay. Results The sample included 130 patients. Median age was 65 years (interquartile range, 56-76 years), and 47.0% (52 of 130) were women. Clinically significant diagnostic error or delay was agreed in 23 (17.7%) patients (κ=0.57; 95% CI, 0.40-0.74). Median age was 65.4 years (interquartile range, 60.3-74.8) and 9 of the 23 (30.1%) were female. Of those with diagnostic error or delay, 60.9% (14 of 23) died in the hospital compared with 19.6% (21 of 107) without; P <.001. Diagnostic error or delay was associated with higher Charlson comorbidity index score, cardiac arrest triage score, and do not intubate/do not resuscitate status. Adjusting for age, do not intubate/do not resuscitate status, and Charlson comorbidity index score, diagnostic error or delay was associated with increased mortality; odds ratio, 5.7; 95% CI, 2.0-17.8. Conclusion Diagnostic errors or delays can be reliably identified and are associated with higher comorbidity burden and increased mortality.

Defining Diagnostic Error: A Scoping Review to Assess the Impact of the National Academies’ Report Improving Diagnosis in Health Care

“…Where there was disagreement, a second review was conducted using the taxonomy delineating stages in the diagnostic process used in the study by Schiff et al 12 : history, physical exam, testing, assessment, referral/consultation, and follow-up. Jayaprakash et al, 32 also using a retrospective medical record review of patients who experienced a rapid response team call, used the NASEM report to operationalize error into 2 parts called diagnostic fidelity—diagnostic error and diagnostic delay—to capture accuracy and timeliness. Diagnostic error was defined as failure to establish an accurate diagnosis or failure to communicate the diagnosis in medical records, and diagnostic delay was the failure to establish a timely explanation of the patient’s health problem and communicate it in the medical records.…”

Analysis of Variation Between Diagnosis at Admission vs Discharge and Clinical Outcomes Among Adults With Possible Bacteremia

“…Increasing attention is being paid to the prevention of diagnostic errors, including misdiagnoses, because these errors have been associated with inappropriate treatment, harm to patients, and increasing costs. [1][2][3] Little is known about the incidence of misdiagnoses in hospitals and their consequences. 4 The common overall estimated percentage of diagnostic error is 10% to 15%, but great variation exists among studies because of a lack of unified terminology and different settings of studies.…”

“…Increasing attention is being paid to the prevention of diagnostic errors, including misdiagnoses, because these errors have been associated with inappropriate treatment, harm to patients, and increasing costs . Little is known about the incidence of misdiagnoses in hospitals and their consequences .…”

What Contributes to Diagnostic Error or Delay? A Qualitative Exploration Across Diverse Acute Care Settings in the United States

“…8 Much of our previous and even current understanding of DEOD is based on autopsy findings, malpractice litigation, surveys, and electronic medical record (EMR) reviews. [9][10][11][12][13][14][15][16][17][18] The World Health Organization and the Agency for Healthcare Research and Quality have prioritized an improved understanding of DEOD. 2 Recent calls to action have sought to improve the detection, use of big data, reporting, and effective prevention of DEOD.…”

“…Singh classified DEODs as “wrong, missed, or delayed diagnoses” and more recently as “missed opportunities” to make a diagnosis 8 . Much of our previous and even current understanding of DEOD is based on autopsy findings, malpractice litigation, surveys, and electronic medical record (EMR) reviews 9–18 . The World Health Organization and the Agency for Healthcare Research and Quality have prioritized an improved understanding of DEOD 2 .…”