Care – Diagnostic Errors

Diagnostic errors, such as missed, incorrect or delayed diagnoses, are complex and diverse safety issues that can cause serious patient harm. The complexity, time-dependent, and team-based nature of the diagnostic process makes the detection and measurement of diagnostic errors a challenging task. When a diagnosis is incorrect or unknown, the patient may receive improper treatment for a present condition, treatment for a condition not actually present or may not receive treatment. This document contains information entered by HIROC subscriber organizations (acute and non-acute) in the Risk Register application to help you in your assessment of the risk.

Key Controls / Mitigation Strategies

Incident Management:

• Comprehensive incident documentation system, including a reporting and review
  framework in place to systematically monitor diagnostic errors and potential
  contributing factors
• Process to review and identify where risk is most likely

Systems, Policies and Procedures:

• Facilitate and support effective interdisciplinary teamwork in the diagnostic process
• Policies regarding oversight of trainees and daily patient assessments
• Process for timely access to ancillary testing and consultants
• Establish communication and escalation pathways
• Develop second reading process for confirmation of all new diagnosis that may lead to
  significant clinical intervention, including new malignancies
• Process to ensure staff refer to surgical booking form or preadmission plan to note tests
  done (e.g. hematology, chemistry, diagnostic tests)
• Process to ensure all test results are available and communicated to the most responsible
  provider in timely manner
• Process to address reporting delays in timely manner
• Establish effective test-result management systems and strategies
• Standardized format/process for communicating pathology results using uniform,
  cancer-specific grading systems and terminology
• Support a culture around high-quality diagnostic services
• Regular laboratory division operational leadership meetings to discuss and address issues
  related to laboratory testing
• Process for effective and up to date utilization of appointment management
• Lab Specimen specific policies:
  » Departmental-specific specimen policies
  » Specimen sign-off process, specimen handling and 2 unique patient identifiers
  » Labelling/Barcoding
• Documentation
  » Standard documentation protocols
  » Document control practices to ensure critical documentation for laboratory
  operation is current and controlled

Equipment / Technology:

• Use of diagnostic health information technology and tools:
  » Alerts, reminders, web-based patient portals (e.g. My Chart)
  » Centralized electronic patient health record
  » Standard care pathways and decision aids
• Equipment replacement process:
  » Early communication of upcoming capital equipment purchase (e.g. equipment
  replacement) and construction/renovation requirements
  » Ongoing coordination in prioritizing and planning equipment replacement projects
  » Timely communication and engagement of appropriate stakeholders
  (e.g. contractors, information technology leads)
  » Frequent status updates on progress of replacement plans
  (e.g. coordination challenges, delays)
• Increase frequency of preventative maintenance and controls
• Digital technology with augmented intelligence to support decision making and amplify
  diagnostic capabilities
• Diagnostic imaging peer review software
• Upgrade obsolete technology that prevents radiologists and other providers from
  visualizing, reviewing or diagnosing due to access issues or poor image quality

Education / Training:

• Patient and family education in the diagnostic process
• Ongoing staff education to minimize cognitive biases in the diagnostic process
• Just culture education, effective teamwork and error prevention training
• Ongoing updates and education on policies and processes (e.g. training on testing for
  specific specimens, revised processes and forms, test result management)
• Implement safety coaches to assist with the uptake of error prevention techniques
• Share safety learnings
• Clinical case conference; department specific rounds/councils
• Strategies and interventions to improve care documentation

Monitoring / Indicators

• Independent audits (e.g. prospective surveillance)
• Monitor chart audits (e.g. emergency department return visits associated with
  diagnostic error)
• Data collected through incident reporting systems including safety events due to
  diagnostic errors and incorrect labeling of specimens
• Frequency of unavailable or improper diagnostic tests, including biopsy results and
  addendum reports, preoperatively/prior to surgery
• Claims data related to diagnostic errors
• Downtime monitoring
• Patient experience survey results
• Report out of patient complaints related to diagnostic errors
• Appropriate number of trained medical and scientific staff and effective
  workload monitoring
• Mortality and Morbidity Committee review of safety reports
• Peer review process:
  » Diagnostic imaging peer review process and software to reduce reporting discrepancy
  and eliminate errors
  » Ancillary reviews for emergency department and diagnostic imaging
  follow-up process
  » Physician peer review program
• Quality assurance:
  » Pathology specific:
  - Consistent / standardized quality assurance processes
  - Pathology quality assurance committee
  - Pathology standards committee
• Adoption of local, regional, provincial quality control processes and initiatives
• Point of care testing quality assurance
• Medical quality assurance compliance audit and monitoring
• Quality assurance oversight for all laboratory services
• Accreditation in place for all laboratory services