Care – Diagnostic Errors

Service: Risk Management
Subject: Care

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
  • 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