By Stacey Kusterbeck
The Leapfrog Group released a report that offers specific guidance on preventing diagnostic errors.1 “Since patients in the ED are at high risk for diagnostic error, there are many practices throughout the report aimed at the ED,” says Missy Danforth, vice president of healthcare ratings at The Leapfrog Group.
Multiple researchers have identified the ED as a high-risk setting for diagnostic error.2,3 “We would urge ED staff and clinicians to identify practices relevant to their local needs and challenges, and then engage hospital leadership to implement those practices,” Danforth says. Two recommendations are relevant to the emergency setting:
• EDs should make it easier for patients and family to report diagnostic errors and concerns. One way leaders can do this is by asking patients if they have identified any errors in their electronic health record visit notes after their visit. Administrators also can direct someone from the hospital’s patient experience department to contact patients by phone or email to encourage reporting of diagnostic errors or concerns. “This person would also follow up with patients who file concerns, and log those concerns in an incident reporting system,” Danforth suggests.
The report highlights a new process at Johns Hopkins Medicine, where patients who were seen in the ED in the previous seven days receive a message via the patient portal with a survey on their diagnostic experience. If the patient is not registered with the patient portal, the patient receives a phone call instead. These patients rate their agreement with statements about the diagnostic process, such as, “I felt that the explanation of my health problem I was given was true.” The patient responses identified some opportunities to improve, including catching missed stroke diagnoses.
To gather feedback during the visit, emergency providers can post signage on how to report diagnostic concerns. To learn feedback after the visit, an ED staffer could contact patients who were discharged with high-risk conditions, such as stroke or sepsis, or patients discharged with a complicated or uncertain diagnosis. “Even though ED physicians may not see their patients again, they can learn a lot about problems with the diagnostic process, and learn about diagnostic errors that are occurring,” Danforth says.
• EDs should use “closed loop” communication to ensure emergency physicians (EPs) review test results and patients learn about the results in a timely manner. The report outlines an initiative at Frederick Health Hospital in Maryland that addresses this issue.
During the height of the COVID-19 pandemic, many patients left the ED before they saw an EP who could give them their COVID-19 test results and appropriate discharge instructions. Leaders conducted a failure mode and effects analysis to learn why. They found patients were leaving the department before they were officially discharged. Those patients did not know how to obtain their test results.
Thus, the ED implemented a protocol whereby clinically trained staff (i.e., nurses and pharmacists) call patients to notify them of any test results still pending at discharge, and communicate the appropriate next steps. Next, the hospital’s service department created scripting to communicate test results.
Many departments lack a good process to close the loop on test results that are pending at the time of discharge, according to the Leapfrog report. “Closed loop reporting is one of the major gaps we identified,” Danforth says.
In fact, Danforth’s own son was discharged from an ED with pending test results — but did not even know an additional test had been performed, only seeing it after reviewing the discharge summary at home.
“There was no information on how to obtain the results — and to date, we still have not received them,” Danforth says. “Many patients and families experience this.”
REFERENCES
1. The Leapfrog Group. Recognizing Excellence in Diagnosis: Recommended Practices for Hospitals. July 2022.
2. Hussain F, Cooper A, Carson-Stevens A, et al. Diagnostic error in the emergency department: Learning from national patient safety incident report analysis. BMC Emerg Med 2019;19:77.
3. Newman-Toker DE, Schaffer AC, Yu-Moe CW, et al. Serious misdiagnosis-related harms in malpractice claims: The “Big Three” - vascular events, infections, and cancers. Diagnosis (Berl) 2019;6:227-240.
A recent report offers specific guidance on preventing diagnostic errors, with some practices aimed at the ED.
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