A Qualitative Analysis of Physician Perspectives on Missed and Delayed Outpatient Diagnosis: The Focus on System-Related Factors

Sarkar, Urmimala; Simchowitz, Brett; Bonacum, Doug; Strull, William M.; López, Andrea García; Rotteau, Leahora; Shojania, Kaveh G

doi:10.1016/s1553-7250(14)40059-x

Cited by 16 publications

(11 citation statements)

References 34 publications

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“… 18 In a separate study of outpatient providers using focus groups, concerns about health system structure and providers’ interactions with one another and with patients far exceeded any discussion of cognitive factors that might affect the diagnostic process. 19 Though neither study was specific to stroke misdiagnosis, these results suggest that improving outpatient diagnostic processes will require focusing attention on the organization of the health care system as well as on providers’ clinical knowledge. Among ischemic stroke patients, a study of malpractice claims found that the most frequent process breakdown was in the initial patient–provider encounter.…”

Section: Diagnostic Errormentioning

confidence: 90%

Diagnostic Challenges in Outpatient Stroke: Stroke Chameleons and Atypical Stroke Syndromes

Wallace

Liberman

2021

NDT

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Failure to diagnose transient ischemic attack (TIA) or stroke in a timely fashion is associated with significant patient morbidity and mortality. In the outpatient or clinic setting, we suspect that patients with minor, transient, and atypical manifestations of cerebrovascular disease are most prone to missed or delayed diagnosis. We therefore detail common stroke chameleon symptoms as well as atypical stroke presentations, broadly review new developments in the study of diagnostic error in the outpatient setting, suggest practical clinical strategies for diagnostic error reduction, and emphasize the need for rapid consultation of stroke specialists when appropriate. We also address the role of psychiatric disease and vascular risk factors in the diagnostic evaluation and treatment of suspected stroke/TIA patients. We advocate incorporating diagnostic timeouts into clinical practice to assure that the diagnosis of TIA or stroke is considered in all relevant patient encounters after a detailed history and examination are conducted in the outpatient setting.

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Section: Diagnostic Errormentioning

confidence: 90%

Diagnostic Challenges in Outpatient Stroke: Stroke Chameleons and Atypical Stroke Syndromes

Wallace

Liberman

2021

NDT

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“…Journey maps allow for identification of steps in the monitoring process that are particularly vulnerable to gaps in patient safety. From the journey map, we identified vulnerabilities in patient safety domains including tasks, technology, organization, people, and environment [21, 22]. Vulnerabilities included patient challenges (homelessness, substance abuse, and mental illness), the cognitive load of tracking patients, time-limiting factors such as the rotating schedules of residents, and overall task burden on providers.…”

Section: Methodsmentioning

confidence: 99%

An electronic registry to improve adherence to active surveillance monitoring among men with prostate cancer at a safety-net hospital: protocol for a pilot study

Cedars

Lisker

Borno

et al. 2019

Pilot Feasibility Stud

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Background The evidence-based practice of active surveillance to monitor men with favorable-risk prostate cancer in lieu of initial definitive treatment is becoming more common. However, there are barriers to effective implementation, particularly in low-resource settings. Our goal is to assess the efficacy and feasibility of a health information technology registry for men on active surveillance at a safety-net hospital to ensure patients receive guideline-recommended care. Methods We developed an electronic registry for urology clinic staff to monitor men on active surveillance. The health information technology tool was developed using the Systems Engineering Initiative for Patient Safety model and iteratively tailored to the needs of the clinic by engaging providers in a co-design process. We will enroll all men at Zuckerberg San Francisco General Hospital and Trauma Center who choose active surveillance as a treatment strategy. The primary outcomes to be assessed during this non-randomized, pragmatic evaluation are number of days delayed beyond recommended date of follow-up testing, the proportion of men who are lost to follow-up, the cancer stage at active treatment, and the feasibility and acceptability of the clinic-wide intervention with clinic staff. Secondary outcomes include appointment adherence within 30 days of the scheduled date. Discussion Use of a customized electronic approach for monitoring men on active surveillance could improve patient outcomes. It may help reduce the number of men lost to follow-up and improve adherence to timely follow-up testing. Evaluating the adoption and efficacy of a customized registry in a safety-net setting may also demonstrate feasibility for implementation in diverse clinical contexts. Trial registration ClinicalTrials.gov identifier NCT03553732 , An Electronic Registry to Improve Adherence to Active Surveillance Monitoring at a Safety-net Hospital. Registered 11 June 2018.

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“…2 Other quality improvement activities might focus on one or more specific conditions for which diagnostic error is a significant problem, such as diagnosing acute stroke in the emergency department, improving the recognition of sepsis and other infections, improving telephone triage for conditions that can be misdiagnosed in care that is not face-to-face, and improving follow-up for findings suspicious for cancer. 45,46 We would expect that through an accumulation of local quality improvement projects, useful indicators of diagnostic performance would likely develop and inform the creation of more rigorous measure sets related to diagnosis that could be used for future safety improvement. For instance, while researchers (including Singh) have developed electronic triggers to help measure diagnostic errors based on certain visit patterns, 47 wider application and implementation beyond the health systems where they were piloted could be facilitated by these quality improvement activities.…”

Section: Alternative Payment Models Designed To Improve Diagnosismentioning

confidence: 99%

Payment Innovations To Improve Diagnostic Accuracy And Reduce Diagnostic Error

Berenson

Singh

2018

Health Affairs

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Diagnostic accuracy is essential for treatment decisions but is largely unaccounted for by payers, including in fee-for-service Medicare and proposed Alternative Payment Models (APMs). We discuss three payment-related approaches to reducing diagnostic error. First, coding changes in the Medicare Physician Fee Schedule could facilitate the more effective use of teamwork and information technology in the diagnostic process and better support the cognitive work and time commitment that physicians make in the quest for diagnostic accuracy, especially in difficult or uncertain cases. Second, new APMs could be developed to focus on improving diagnostic accuracy in challenging cases and make available support resources for diagnosis, including condition-specific centers of diagnostic expertise or general diagnostic centers of excellence that provide second (or even third) opinions. Performing quality improvement activities that promote safer diagnosis should be a part of the accountability of APM recipients. Third, the accuracy of diagnoses that trigger APM payments and establish payment amounts should be confirmed by APM recipients. Implementation of these multipronged approaches can make current payment models more accountable for addressing diagnostic error and position diagnostic performance as a critical component of quality-based payment. E Rationale For Addressing Diagnostic Accuracy In Payment ReformThe prevailing payment system that is based on fee-for-service fully tolerates and, to some unfortunate extent, even encourages diagnostic error.

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A Qualitative Analysis of Physician Perspectives on Missed and Delayed Outpatient Diagnosis: The Focus on System-Related Factors

Cited by 16 publications

References 34 publications

Diagnostic Challenges in Outpatient Stroke: Stroke Chameleons and Atypical Stroke Syndromes

Diagnostic Challenges in Outpatient Stroke: Stroke Chameleons and Atypical Stroke Syndromes

An electronic registry to improve adherence to active surveillance monitoring among men with prostate cancer at a safety-net hospital: protocol for a pilot study

Payment Innovations To Improve Diagnostic Accuracy And Reduce Diagnostic Error

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