The National Academy of Medicine determined in the 2015 landmark publication Improving Diagnosis in Medicine that everyone will likely experience at least one diagnostic related error in their lifetime, sometimes with devastating consequences. Diagnostic errors occur in every healthcare setting and in some cases, are preventable. Yet, this is an emerging topic harkening to the early days of the patient safety movement when well defined action plans were limited.
Establishing a correct diagnosis is a complex, often evolving process that requires gathering information over time, from different sources and integrating, interpreting and evaluating it in a pathophysiologic framework. Well established cognitive biases affect everyone as we make decisions and interpret information. While widely understood by cognitive scientists, anticipating, managing and eliminating these biases is challenging. Errors in the process can occur at any of the multitude of steps beginning with hearing, understanding and interpreting symptoms from the patient.
A well-established “change package” is not available now as in other HIIN topics. Measuring the incidence of diagnostic errors has yet to bear fruit and methods to demonstrate objective improvement are nascent. Early principles about how to prevent, identify and mitigate problems with both the diagnostic process and outcomes from errors along the way are being clarified and focus areas are rapidly appearing.
The HRET HIIN will monitor and share developing practices to prevent and reduce diagnostic errors. As effective methods to reduce diagnostic errors emerge we will rapidly disseminate to HIIN participants to strengthen safety programs in hospitals.Partnership for Patients (PfP) Goal