Background: Diagnostic error may occur in up to 5% of all adult hospitalizations, leading to prolonged length of stay, higher cost, and significant morbidity and mortality. Improving diagnostic safety requires measurement, analysis, and learning accelerated by dissemination. While safety is at the forefront of hospital priorities, organizational readiness to address diagnostic safety lacks consistent deployment and monitoring.
Methods: Achieving Diagnostic Excellence through Prevention and Teamwork (ADEPT) is a 16-hospital national study seeking to reduce diagnostic error among adult inpatient medicine patients. These geographically distributed sites primarily represent academic medical centers. The ADEPT team developed a 37-item novel organizational assessment instrument distributed via email to leads at each site in early 2023. Data captured included multiple choice and free text responses about case analysis, safety, and work around diagnostic improvement.
Results: All 16 sites completed the assessment. Each site completed case reviews referred by providers, with 87% of sites having structured mortality review and 37% having structured review of cases with care escalation, such as ICU transfer. While diagnostic error discussion may arise in these reviews, less than half (43%) of programs incorporated diagnostic error into their existing patient safety and quality infrastructure. 75% of programs had dashboards for cases of inpatient death and 31% for cases requiring escalation of care. None had data visualization of diagnostic error rates. Most organizations had programs to provide frontline providers emotional and mental health support (87%), though the support typically required outreach from the impacted clinician. The majority of organizations had patient and family advisory committees (87%), but only three sites worked with them routinely at the division level (19%). Half of the sites had begun measuring diagnostic error through triggered case review. One site had developed a dedicated system for sharing diagnostic opportunities, the Diagnostic Error Reporting System (DERS).In terms of interventions to improve diagnostic safety, some sites reported improving the culture of feedback and building a diagnostic reasoning curriculum. One site focused on teamwork, improving interprofessional communication tools, and psychological safety training. Another site emphasized patient engagement through the promotion of electronic patient access to medical records.Many sites reported barriers to diagnostic improvement, including complexity and diversity of diagnosis in hospital medicine, limited financial support, the need for leadership development, and lack of institutional prioritization.
Conclusions: There is large variation in structure, process, and support around measuring, tracking, and learning from diagnostic opportunity, likely representing broader uncertainty around the best way to organize and coordinate a diagnostic excellence program. As the evidence for methods to reduce diagnostic error grows, it will be necessary to establish best practices around how to structure and adequately resource dedicated diagnostic safety programs, including patient and interprofessional engagement strategies, and building leadership commitment.