In another facility, it may be due to lack of monitoring of patients who are experiencing deterioration on a medical-surgical unit. • When using a specific PSP, consideration must be given to potential new harms that can be introduced. For example, strategies to improve anticoagulation-related events must be balanced with strategies used to reduce venous thromboembolism. • PSPs are not implemented in isolation and are often part of a broader safety strategy. The strategy often relies on a strong safety culture, teamwork, communication, and involvement of the patient and family. These cross-cutting practices are the foundation for success. Diagnostic Errors Diagnostic error is an increasingly-recognized threat to public health, with estimates of 5% of adults being affected in the outpatient environment. 1 In the hospital setting, diagnostic error is responsible for 6% to 17% of adverse events. 2 Diagnostic error has also been shown to be responsible for more closed malpractice claims than other causes. 3 The Institute of Medicine (now the National Academy of Sciences), in its seminal report on diagnostic safety, concluded that “most people will experience at least one diagnostic error in their lifetime.” 4 A diagnostic error is “the failure to (a) establish an accurate and timely explanation of the patient’s health problem(s) or (b) communicate that explanation to the patient.” 1 This definition focuses on the outcomes of the diagnostic process, recognizing that diagnosis is an iterative process that solidifies as more information becomes available. The diagnosis needs to be timely and accurate so that appropriate treatment is initiated to optimize the patient’s outcome. Any gaps that arise in the diagnostic process can lead to error. This chapter reviews four patient safety practices that have the potential to decrease diagnostic errors: the use of clinical decision support (CDS); result notification systems (RNS); education and training; and peer review. •
Clinical Decision Support Diagnostic error is a complex and multifaceted problem that requires systems solutions to achieve the necessary changes. Advancements in health information technology (IT) represent thoughtful and sophisticated ways to reduce delayed, missed, or incorrect diagnoses. Contributions of health IT include more meaningful incorporation of evidence- based diagnostic protocols with clinical workflow, and better usability and interfaces in the electronic health record (EHR). CDS provides clinicians, staff, patients or other individuals with knowledge and person-specific information, intelligently filtered or presented at appropriate times, to enhance health and healthcare. CDS encompasses a variety of tools to enhance decision making in the clinical workflow. These tools include computerized alerts and reminders to care providers and patients; clinical guidelines; condition-specific order sets; focused patient data reports and summaries; documentation templates; diagnostic support, and contextually relevant reference information, among other tools. CDS represents a range of different interventions, from documentation templates to popup alerts. The knowledge bases triggering CDS differ as well. Rules- based or logic-based CDS often takes the form of IF-THEN rules. More advanced CDS leveraging artificial intelligence (AI) and machine learning taps awareness of past experiences and patterns in clinical data. These techniques have generated interest in their potential to better augment clinician intelligence and support decision making. Several patient safety researchers have suggested that health IT, including CDS, can be leveraged to improve diagnosis, although the data have been mixed. An example of a CDS are differential diagnosis (DDX) generators. DDX generators are programs that assist healthcare professionals in clinical decision making by generating a differential diagnosis based on a minimum of two items of patient data. DDX generators provide a list of potential diagnoses for consideration, sometimes in order of likelihood based on available information, as a means to improve diagnosis. Several investigational CDS tools exist to assist with diagnostic study interpretation, including imaging studies, electrocardiograms (ECGs), and pathology. Although these CDS tools are proof-of- concept in nature, they demonstrate the potential to augment clinician diagnostic performance but not completely replace it. Use in Imaging Three papers have evaluated techniques to assist with interpretation of imaging studies. All were investigational in nature, describing the development and validation of the models. Herweh et al. (2016) compared the diagnostic performance of an automated machine-learning algorithm to detect acute stroke on CT scans using a standardized scoring method to the performance of stroke experts and novices using the algorithm. 5 Although this study had a small sample size, the automated tool showed similar scoring results to that of experts and better performance than the novices.
Introduction Every year, millions of patients suffer injuries or die because of unsafe or poor-quality health care. Many medical practices and risks associated with health care pose major challenges for patient safety and contribute significantly to the burden of harm due to unsafe care. Improving patient safety involves every level of care, from individual practitioners to practice-based systems of operation and all the way up to the highest levels of health care policy reforms. This learning activity summarizes a range of issues related to patient safety practices (PSPs) that are relevant to practicing clinicians. The activity is based on The Making Health Care Safer report from the Agency for Healthcare Research and Quality (AHRQ). Previous AHRQ reports have helped to reduce harm and improve the safety and quality of care for patients. The reports analyze the evidence for various patient safety practices and have also identified contextual factors that contribute to successful PSP implementation. The reports have helped to shape national discussion regarding patient safety issues on which providers, payers, policymakers, and patients and families should focus. This activity seeks to support a culture of safety across the healthcare continuum, including in nursing homes, home care, outpatient, and ambulatory settings, and during care transitions. The scope of this activity is intentionally broad and includes issues such as addressing the opioid crisis and emerging health risks (e.g., multidrug-resistant organisms) and overall directives to “put patients first” and to reduce provider burden and burnout. Patient safety practices are discrete and clearly-recognizable structures or processes used for the provision of care that are intended to reduce the likelihood and/or severity of harm due to systems, processes, or environments of care. A PSP may have varying degrees of evidence to support its ability to prevent or mitigate harm. This activity focuses on PSPs chosen for the high-impact harms they address and include diagnostic errors, failure to rescue, infections, and nursing-sensitive conditions. The most significant harms patients face continue to be found in higher acuity settings, such as the emergency department and ICU. One “setting” that poses a unique threat to patients is the transition between one setting and another: the hospital to the outpatient setting, in particular. Several broad themes will emerge from this learning activity: • More than one PSP can be used to reduce a given harm. • The context in which a PSP is implemented determines success. • Selecting a particular PSP should be based on the root cause of the harm. If a facility is experiencing an increase in sepsis mortality, the root cause may be a lack of recognition of patients with sepsis arriving to the ED.
CDS offers solutions integrated into the workflow to address diagnostic errors by providing stakeholders with knowledge and person-specific information, intelligently filtered or presented at appropriate times, to improve decision making and communication. RNSs aim to address lapses in communication, a contributing factor to delayed diagnosis and treatment of patients in both ambulatory and inpatient settings. Education and training on the diagnostic process enhance clinical reasoning and decrease biases. Peer review identifies potential diagnostic errors before they reach the patient and provides feedback with the intent of improving clinical practice and quality.
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