Care – Diagnostic Errors
Diagnostic errors, such as missed, wrong, 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 wrong or unknown, the patient may receive improper treatment for a present condition, or treatment for a condition not actually present. 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.
Ranking / Ratings
- Likelihood – average score 3.44
- Impact – average score 4.11
The Risk Register allows for risks to be assessed on a five-point likelihood and impact scale, with five being the highest.
Key Controls / Mitigation Strategies
- Incident Management
- Comprehensive incident documentation system, including a reporting and review framework or program in place to systematically monitor diagnostic errors and their underlying contributing factors
- Incident review levels / types:
- Unit / team-based incident review
- Morbidity and mortality review process
- Corporate mortality review to measure diagnostic errors
- Quality of care reviews
- Reviews requested by the Coroner’s office
- Build a culture around high-quality diagnostic services
- Policies and Procedures
- Facilitate and support interdisciplinary teamwork in the diagnostic process
- Policies regarding oversight of trainees and daily patient assessments
- Establish effective test-result management systems and strategies
- Timely access to ancillary testing
- Timely access to consultants
- Process to ensure staff refer to surgical booking form or preadmission plan to note tests done (e.g. hematology, chemistry, diagnostic tests)
- Accreditation in place for all laboratory services
- Regular laboratory division heads or senior operational leadership meetings to discuss and address issues related to laboratory testing
- Lab Specimen specific:
- Departmental specific specimen policies
- Specimen sign-off process
- Specimen handling / identification
- Labelling
- Ongoing update of policies to reflect new processes and forms
- Documentation:
- Standard documentation protocols
- Document control practices to ensure critical documentation for laboratory operation is current and controlled
- Strategies / interventions to improve care documentation
- 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 work care pathways and decision aids
- Equipment replacement process:
- Ongoing coordination in prioritizing, planning and implementation of equipment replacement projects
- Early communication of upcoming capital equipment purchase (e.g. equipment replacement) and potential required work plans
- 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)
- Downtime monitoring
- 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
- Use of diagnostic health information technology and tools:
- Education / Training
- Patient and family education in the diagnostic process
- Ongoing staff education to minimize cognitive biases in the diagnostic process
- Staff education on new forms and processes
- Lab staff education on policies and processes (e.g. training on testing for specific specimens)
- Mandatory error prevention methods training; implement safety coaches to assist with the uptake of error prevention techniques
Monitoring / Indicators
- Independent audits (e.g. prospective surveillance)
- Internal chart audits (e.g. emergency department return visits)
- Data collected through incident reporting systems
- Rate of safety events due to diagnostic errors
- Claims data related to diagnostic errors
- Patient experience survey results
- 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
- Secondary reviews for emergency department and diagnostic imaging follow-up process
- Physician peer review program
- Preoperative review process (e.g. preoperative checklist) of all diagnostic tests, including biopsy results and addendum reports, prior to surgery
- Quality assurance:
- Pathology specific:
- Consistent / standardized quality assurance processes
- Pathology quality assurance committee
- Pathology standards committee
- Interpretive quality assurance program
- Point of care testing quality assurance
- Medical quality assurance compliance audit / monitoring
- Adoption of local, regional, provincial quality control processes and initiatives
- Quality assurance oversight for all laboratory services
- Pathology specific: