Diagnostic Errors

1. What is the decision or change you are facing or struggling with where a summary of the evidence would be helpful?

LHSs would like evidence on: (1) the epidemiology (e.g., type, costs, frequency) of diagnostic failures in acute care settings, particularly in emergency department admissions and (2) effective strategies to mitigate or prevent diagnostic failures. This evidence is particularly needed in emergency department admissions as there is acuity and added complexity due to the involvement of many different providers.

(Note: The panel discussed diagnostic failures during the October 25 LHS Panel meeting in the context of the IOM definition of diagnostic failures: failure to establish an accurate and timely explanation of the patient’s health problem or communicate that explanation to the patient.)

2. Why are you struggling with this issue?

• Diagnostic failures, including delays in diagnosis, often result in patient harm
• Diagnostic failures are a complex topic in large part because the causes are wide and varied; as a result, they are difficult to address
• Published data on missed diagnoses in particular is scant
• Because of the complexity and diverse causality, it is difficult to make a business case to LHS leaders to address diagnostic failures

3. What do you want to see changed? How will you know that your issue is improving or has been addressed?

An evidence report on the epidemiology of diagnostic failures would help to: (1) move diagnostic failures from a concept to something more quantifiable and (2) serve as the basis for a business case to promote investment of resources in this area by health systems. Other anticipated changes would include:

• Increased focus and resources across health systems – at multiple levels – on preventing diagnostic failures/errors; in the long-term, this increased focus should decrease the prevalence of diagnostic failures and improve patient safety
• Increased use of psychology knowledge to address diagnostic failures

4. When do you need the evidence report?

Sun, 11/08/2020

5. What will you do with the evidence report?

LHSs will use an evidence report to make a business case to increase focus on the prevention of diagnostic failures and, in turn, guide efforts to address/reduce those failures.

Supporting Document

https://effectivehealthcare.ahrq.gov/sites/default/files/webform/docs/0892_nomination_supplemental_document_redacted.docx

Title or short description: Diagnostic Errors

Comments or notes about this file: The LHS Champion for this topic shared, “This is a hot topic – but better to take time and really have a helpful document.”

[Nominator contact information redacted from file]

(Optional) About You

What is your role or perspective?

Learning Health System Representative

If you are you making a suggestion on behalf of an organization, please state the name of the organization:

Northwell Health

May we contact you if we have questions about your nomination?

Yes

Title: SVP & Chief Quality Officer, Associate Chief Medical Officer, Professor of Medicine