Improving diagnostic systems safety through research, education, and innovation
Diagnostic errors are both frequent and harmful, resulting in substantial, preventable morbidity and mortality and excess healthcare costs while being among the most frequent reasons for medical malpractice claims. In fact, national reports estimate most Americans will experience a diagnostic error at least once in their lifetime and women and racial and ethnic minorities are more likely to not only experience more diagnostic error but more significant harm due to diagnostics errors.
The MedStar Health Center for Diagnostic Systems Safety addresses diagnostic error using structured, evidence-based systems-engineering approaches to improve care quality, value, patient safety, patient experience, and overall health outcomes. We provide scientific, educational, programmatic, and administrative leadership for diagnostic safety efforts across the MedStar system, with a focus on three core pillars:
Research and application
The Center acts as a research collaborative to support researchers in their work to develop active, bi-directional studies that seek to test interventions to improve diagnostic systems in a real-world clinical environment.
Integrating current and planned research efforts, the Center supports operational efforts through enhanced transparency of diagnostic performance. For example, employ metrics and indicators to measure and track diagnostic safety to identify trends and areas for improvement.
Education and training
The Center supports current and new training opportunities including didactic sessions, online training, and simulation for educational interventions targeting clinical reasoning and diagnostic safety, as well as training opportunities to support patient education and co-production of care.
This grant focused on developing program support and expertise related to improving diagnostic safety and quality. Our team produced four diagnostic improvement tools to include the TeamSTEPPS for Diagnosis Improvement, the Toolkit for Engaging Patients To Improve Diagnostic Safety, Calibrate Dx: A Resource To Improve Diagnostic Decisions, and Measure Dx: A Resource To Identify, Analyze, and Learn From Diagnostic Safety Events. To date, this contract has resulted in seventeen AHRQ issue briefs and six peer-reviewed journal articles on various diagnostic safety topics.
The underdiagnosis and undertreatment of cardiovascular disease or heart disease in women is an important health concern, and one that is due to several factors. Namely, cardiovascular disease can be challenging to diagnose in women as it sometimes presents with different symptoms and the lingering perception that heart disease is a condition that primarily impacts men. Our transdisciplinary team is applying a mixed-methods systems approach to understand the complex interplay of factors contributing to errors in heart disease in women in the ambulatory care setting and co-design and evaluate adaptive solutions. Investigators are applying a systems engineering approach to evaluate factors including but not limited to the physical environment, social determinants, clinical care, and health IT. To date, this grant has resulted in 28 conference presentations, three workshops, and four peer reviewed publications.
Diagnostic errors are a significant public health concern and the leading cause of harm due to medical care in the U.S.; yet research to date has principally focused on the clinician as the center of both the problems and the solutions. Four unique workstreams within our Center shifts this paradigm by convening diverse scientists and patients around research questions developed and prioritized by patients yielding patient-centered diagnostic safety solutions and reductions in diagnostic safety events. By providing clear evidence by measuring the problem (Safety I) and devising solutions to build diagnostic team resilience (Safety II), our Center has high potential to improve diagnostic safety for all patients in the U.S.
Central to the diagnostic process are critical cognitive processes such as the physician’s ability to find and process relevant information, reason with this information, and formulate a diagnosis. While it is recognized that the electronic health record (EHR) contributes to the problem of diagnostic error, the identification and relative contribution of how, when, and why the EHR contributes to diagnostic error are poorly described. This project focuses on identification of EHR contributions to diagnostic error to deploy a suite of solutions to improve software, user, and system (workflow).
Adults over the age of 65 are at the greatest risk for preventable harms and death and a higher risk for diagnostic errors due to a myriad of reasons (e.g., complex medical histories, cognitive or sensory impairments. To help improve communication during the patient-provider encounter, we modified an existing AHRQ “Be the Expert on You” note sheet. By recruiting and partnering with older adult patients in four one-hour focus group sessions, we developed a two-page communication and clinic workflow tool for use in a family practice setting that serves a diverse population of patients. Practice-wide implementation of the note sheet is underway.
AHRQ R01: Improving Diagnostic Equity in Ambulatory care Settings (I.D.E.A.S.): Research to Practice
The diagnostic process is an iterative, time-dependent, and collaborative decision-making process under uncertainty to reach an explanation for the patient’s health condition(s) and communicate this explanation to the patient. The IDEAS study is evaluating diagnostic errors in the context of diagnostic equity and diagnostic uncertainty through the application of decision-modeling and human factors methodologies. The work includes identifying and conceptualizing diagnostic equity and diagnostic uncertainties in a subset of ambulatory patient records to establish the incidence of diagnostic error; and analyzing the patterns and sources of diagnostic disparities and estimate the effects of diagnostic uncertainty on diagnostic equity. The research team will propose, co-design, and evaluate patient-centered solutions to address diagnostic equity and mitigate diagnostic error in primary care.