Background: Diagnostic error is a major threat to the safety of hospitalized patients, affecting as many as 1 in 4 patients and leading to 7% of inpatient deaths. However, diagnostic error remains difficult to identify and measure, particularly in the hospital setting, where determination of an error relies on medical record review. Measurement difficulty also complicates the ability to implement efforts to reduce diagnostic error. A diagnostic excellence program that aims to measure, analyze, and reduce diagnostic error can improve patient safety.
Purpose: To build a Hospital Medicine diagnostic excellence program to measure, analyze, and reduce diagnostic error
Description: As part of a national research collaborative through the Achieving Diagnostic Excellence through Prevention and Teamwork (ADEPT) study , we built a diagnostic excellence program focused on achieving diagnostic excellence. We recruited hospitalists interested in diagnostic error and patient safety to serve as chart reviewers to identify and measure cases of diagnostic error. Our team included junior faculty as well as mid-career faculty with case review experience and engaged patient safety leaders from our Hospital Medicine Division and health system. As part of ADEPT, our reviews targeted Hospital Medicine patients who experienced ‘trigger events’ of inpatient death, ICU transfer, or a Rapid Response Team call. Two hospitalist reviewers randomly selected trigger events for structured chart review using evidence-based tools to identify diagnostic error. Reviewers volunteered their availability for cases in weekly increments and were assigned cases by leaders . Our program had several early realizations. A larger review team is highly advantageous, given the time intensity of the chart reviews and the changes in personal bandwidth over time and have subsequently recruited additional team members. Additionally, efforts of our team were aided by a program manager who was key in helping distribute and track case assignments and completion. We learned that reviewers preferred to receive smaller, more frequent assignments of cases rather than less frequent, larger batches and adapted the case assignment approach accordingly. As most reviewers were completing case review assignments just prior to meeting with their co-reviewer, we encouraged early, proactive meeting setting . We development an audit/feedback mechanism provided twice monthly to show reviewers their case completion data and incomplete cases. We built a strong partnership with our health system Chief Quality Officer and Patient Safety Team, including meeting regularly. We embedded our chart review work formally into patient safety via the creation of a subcommittee of our health system Patient Safety Committee; this also allows the chart review to fall under legally protected patient safety work. Cases found to have a diagnostic error are submitted for individual review as part of Incident Reports, with summaries shared with Patient Safety Committee on a regular basis. Future directions include building a program for physician feedback for both hospitalists and trainees and exploring technological solutions including via artificial intelligence to reduce measurement burden and potentially identify triggers prior to patient decompensation.
Conclusions: Hospitalists are poised to be leaders in inpatient diagnostic safety, though successfully building diagnostic excellence programs will take expertise and resources that require institutional investment.