Why It Matters
Diagnostic error - both accurate diagnosis and timely communication about test results - is a big problem that could benefit from systematic process redesign.
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Diagnosis Is a Process: Experts Offer Advice on Diagnostic Error and Delays in Patient Safety

By Madge Kaplan | Thursday, January 7, 2016
Diagnostic error in patient safety

Research suggests that diagnostic error contributes to about 10 percent of patient deaths. But very little patient safety work to date has focused on this issue.

All that is changing, thanks to a handful of experts and organizations who have spent years studying the causes of diagnostic error and developing solutions. A new IOM report released in September 2015, “Improving Diagnosis in Health Care,” calls for urgent action on the problem. It's a difficult one to get a handle on, as it encompasses both the need to make an accurate diagnosis as well as to communicate the information to the patient, all in a timely manner. Each step requires unique skills and processes that must operate as one reliable system.

“The report goes a long way toward doing something very important for improvers, which is to make the invisible visible,” said Kedar Mate, MD, IHI Senior Vice President, on a recent WIHI dedicated to the issue. Other experts joined Mate on the free audio program to discuss the challenges and solutions to diagnostic error and some of the guests’ takeaways from the IOM report, including:   

  • Diagnostics is a process, not a discrete event such as a surgery, and it evolves over time with new input.
  • The process is complex, with multiple steps, transitions, and contributors in different locations.
  • The hallmarks of good diagnosis mirror high quality health care delivery more generally: communication, openness, humility, and teamwork — with the patient as a key member of the team.

What stands in the way of developing good diagnostic processes?

One barrier is the lack of a patient-centered culture in many organizations. Patients often don’t feel welcome to speak up about their diagnostic concerns. Thomas Gallagher, MD, a pioneer in patient safety and diagnostic errors, cited one study his group led that found 25 percent of cancer patients thought a breakdown in diagnosis occurred but only 10 percent reported their concerns. The most common reason for their silence? A fear that raising their hand might adversely affect their care.

Another challenge is the cognitive tendency to make assumptions and stick to them. Mark Graber, MD, who for decades has been shining a spotlight on diagnostic errors, said clinicians often make the wrong diagnosis when they’re absolutely certain they’re right — and this happens often too quickly, upon seeing the patient and barely getting started with an exam. Providers also tend to make diagnoses based on what they’ve seen before. Intuition is a great asset, Graber said, but the data show that confidence is not a reliable index of whether a diagnosis is correct.

Patients and providers alike hold misconceptions about diagnostic error that contribute to the problem. The Society to Improve Diagnosis in Medicine has highlighted top myths about diagnostic errors held by patients, including the assumption that no news is good news, that their doctors are talking with one another, and that there is always a simple diagnosis. Physicians, too, hold incorrect beliefs about diagnostic error: that it won’t happen to them, that they always make a complete differential diagnosis, and that most diagnostic errors involve rare or uncommon diseases.

What can health systems do about diagnostic error?

To avoid jumping to conclusions about a diagnosis, Graber suggested clinicians follow a few basic steps: Take a diagnostic time-out by stopping for a minute to reflect. Ask colleagues for second opinions. Go talk to the radiologist or pathologist who did the test you ordered. “I guarantee you,” Graber said, “They know a heck of a lot more than what’s in their report.” Such input can be invaluable in making the right diagnosis. For more tips, check out Graber’s article, “Minimizing Diagnostic Error in Health Care: Ten Things You Could Do Tomorrow.

The new thinking on better diagnoses points directly to improvement science, which offers a systematic way to redesign flawed processes. “This is a hard area to quantify. It’s hard to wrap our arms around it; to measure it,” Mate said. “But we’re making progress. And once we have a system to measure, we can start to apply the tools of modern management science and quality improvement to start eliminating defects and processes that are failing across the system.”

One aspect of the diagnostic process is managing test results. Jennifer Lenoci-Edwards, RN, MPH, IHI Director of Safety, explained how even just this one part of the process is actually six steps over time and distance — multiple specialists, departments or even institutions. IHI is offering a new virtual training program to help organizations better manage test results, Building Reliable Systems to Reduce Delays in Diagnosis, which begins January 12.


In this video clip (above), WIHI guest and IHI Safety Director Jennifer Lenoci-Edwards describes how improvement science can help front-line providers avoid diagnostic errors.

A final word of advice

Experts agreed that the time for action is now: Start small, looking at test result procedures or the time it takes to get diagnoses to your patients. It doesn’t really matter where you start, just pick a step in the process, and observe how you’re doing. Think about how you could start tracking this data, and you’re on the way.

You’ll find all the information from this WIHI, including slides, audio broadcast, and chat discussion, posted in the WIHI archive. Download this broadcast as a podcast by searching for “IHI” through iTunes or your favorite podcast app.

Learn more in the Patient Safety Executive Development Program, which runs from March 3-9 in Cambridge, Massachusetts, USA.


Photo credit: U.S. Navy. U.S. Government work; no copyright restrictions apply.

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