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Defining excellence: next steps for practicing clinicians seeking to prevent diagnostic error

View Article: PubMed Central - PubMed

ABSTRACT

The Institute of Medicine (IOM) released its report on diagnostic errors in September, 2015. The report highlights the urgency of reducing errors and calls for system-level intervention and changes in our basic clinical interactions. Using the report’s controversial definition of diagnostic error as a starting point, we introduce the issues and the potential impact on practicing physicians. We report a case used to illustrate this in an academic conference. Finally, we turn to the challenge of integrating these ideas into the traditional peer-review process. We argue that the medical community must evolve from understanding diagnostic failures to redesigning the diagnostic process. We should see errors as steps toward diagnostic excellence and reliable processes that minimize the risk of mislabeling and harm.

No MeSH data available.


Diagnostic error: Relationship between process, label error, and risk of harm.
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Figure 0003: Diagnostic error: Relationship between process, label error, and risk of harm.

Mentions: As with other safety events, we should be hunting for learning opportunities and analyzing them as quickly as possible. We designed Fig. 3 to illustrate how opportunities exist in almost every case, particularly the innocuous ones. As we've learned in the safety literature, fixing seemingly innocuous errors can save us from major errors down the road. Instead of waiting for a pharmacy or nurse to flag a case, then, we should have physician huddles to audit for surprise diagnoses. Many hospitals have otherwise fairly robust safety reporting systems, but the confidentiality of prevailing medical–legal models of peer review makes it difficult to include physician mistakes, particularly mistakes involving cognitive or professional judgment errors. The confidentiality of our peer-review committees protects our reputations and allows us to make difficult but controversial decisions in safety. Ironically, however, that same protection undermines system ownership of diagnostic errors and facilitates repetition. In contrast, embedding daily review with system-wide analysis and tracking of minor cases should achieve the dramatic gains for accurate and efficient diagnosis that we have seen with other safety problems like central line infections and falls.


Defining excellence: next steps for practicing clinicians seeking to prevent diagnostic error
Diagnostic error: Relationship between process, label error, and risk of harm.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC5016746&req=5

Figure 0003: Diagnostic error: Relationship between process, label error, and risk of harm.
Mentions: As with other safety events, we should be hunting for learning opportunities and analyzing them as quickly as possible. We designed Fig. 3 to illustrate how opportunities exist in almost every case, particularly the innocuous ones. As we've learned in the safety literature, fixing seemingly innocuous errors can save us from major errors down the road. Instead of waiting for a pharmacy or nurse to flag a case, then, we should have physician huddles to audit for surprise diagnoses. Many hospitals have otherwise fairly robust safety reporting systems, but the confidentiality of prevailing medical–legal models of peer review makes it difficult to include physician mistakes, particularly mistakes involving cognitive or professional judgment errors. The confidentiality of our peer-review committees protects our reputations and allows us to make difficult but controversial decisions in safety. Ironically, however, that same protection undermines system ownership of diagnostic errors and facilitates repetition. In contrast, embedding daily review with system-wide analysis and tracking of minor cases should achieve the dramatic gains for accurate and efficient diagnosis that we have seen with other safety problems like central line infections and falls.

View Article: PubMed Central - PubMed

ABSTRACT

The Institute of Medicine (IOM) released its report on diagnostic errors in September, 2015. The report highlights the urgency of reducing errors and calls for system-level intervention and changes in our basic clinical interactions. Using the report’s controversial definition of diagnostic error as a starting point, we introduce the issues and the potential impact on practicing physicians. We report a case used to illustrate this in an academic conference. Finally, we turn to the challenge of integrating these ideas into the traditional peer-review process. We argue that the medical community must evolve from understanding diagnostic failures to redesigning the diagnostic process. We should see errors as steps toward diagnostic excellence and reliable processes that minimize the risk of mislabeling and harm.

No MeSH data available.