Measures to Improve Diagnostic Safety in Clinical Practice

Abstract

Timely and accurate diagnosis is foundational to good clinical practice and an essential first step to achieving optimal patient outcomes. However, a recent Institute of Medicine report concluded that most of us will experience at least one diagnostic error in our lifetime. The report argues for efforts to improve the reliability of the diagnostic process through better measurement of diagnostic performance. The diagnostic process is a dynamic team-based activity that involves uncertainty, plays out over time, and requires effective communication and collaboration among multiple clinicians, diagnostic services, and the patient. Thus, it poses special challenges for measurement. In this paper, we discuss how the need to develop measures to improve diagnostic performance could move forward at a time when the scientific foundation needed to inform measurement is still evolving. We highlight challenges and opportunities for developing potential measures of “diagnostic safety” related to clinical diagnostic errors and associated preventable diagnostic harm. In doing so, we propose a starter set of measurement concepts for initial consideration that seem reasonably related to diagnostic safety, and call for these to be studied and further refined. This would enable safe diagnosis to become an organizational priority and facilitate quality improvement. Health care systems should consider measurement and evaluation of diagnostic performance as essential to timely and accurate diagnosis and to the reduction of preventable diagnostic harm.

Operational measurement of diagnostic safety: state of the science

“…Diagnostic performance can be defined not only by accuracy and timeliness but also by efficiency (e.g., minimizing resource expenditure and limiting the patient's exposure to risk) [21]. Measurement of diagnostic performance should hence consider the broader context of valuebased care, including quality, risks, and costs, rather than focus simply on achieving the correct diagnosis in the shortest time [16,22].…”

“…For instance, measures of diagnostic test result follow-up may focus specifically on abnormal test results that are suggestive of serious or time-sensitive diagnoses, such as cancer [87]. Examples of diagnostic safety measures could include the proportion of documented "red-flag" symptoms or test results that receive timely follow-up, or the proportion of patients with cancer newly diagnosed within 60 days of first presentation of known red flags [16]. Depending on an HCO's priorities, safety leaders could consider additional development, testing, and potential implementation of measure concepts proposed by NQF and other researchers [8,16,88].…”

“…Further, measurement is only valuable to the extent that it is actionable and leads to improved care delivery and outcomes [15]. New and emerging measures of diagnostic safety should therefore be evaluated not only in terms of their validity but also their potential to inform pragmatic strategies to improve diagnosis [16]. At present, most of the tools and strategies that organizations use to detect patient safety concerns cannot always specifically detect diagnostic error, and even when these errors are uncovered, analysis and learning are limited.…”

Improving Diagnosis Through Education

“…Thus, diagnosis curricula must not be removed from the health care system but instead ensure that trainees are exposed to the real ecosystem of medical practice with all its chaos, flaws, and opportunities. 12 Trainees must learn to practice with electronic health information technologies rather than in spite of them, 12 and they must know how to take advantage of the many affordances these technologies provide to improve diagnosis. These include immediate access to knowledge repositories, sophisticated decision support tools for differential diagnosis, and facilitated access to second opinions and tools to help ensure reliable communication.…”

Tracking Progress in Improving Diagnosis: A Framework for Defining Undesirable Diagnostic Events

“…6 Tools to improve the accuracy and reliability of diagnostic error measurement are under development, but are still primarily research tools and may be difficult for a health system to implement. 13 Given the wide scope, variability, and time scale of the diagnostic process, projects to improve diagnosis in one area (such as cancer) may have little effect on another area (such as sepsis or pulmonary embolus). Similarly, it is unknown whether interventions in one setting, such as primary care, would be useful in others, such as inpatient settings.…”