The Diagnostic Error Index: A Quality Improvement Initiative to Identify and Measure Diagnostic Errors

Abstract

Objective To develop a diagnostic error index (DEI) aimed at providing a practical method to identify and measure serious diagnostic errors.Study design A quality improvement (QI) study at a quaternary pediatric medical center. Five well-defined domains identified cases of potential diagnostic errors. Identified cases underwent an adjudication process by a multidisciplinary QI team to determine if a diagnostic error occurred. Confirmed diagnostic errors were then aggregated on the DEI. The primary outcome measure was the number of monthly diagnostic errors.Results From January 2017 through June 2019, 105 cases of diagnostic error were identified. Morbidity and mortality conferences, institutional root cause analyses, and an abdominal pain trigger tool were the most frequent domains for detecting diagnostic errors. Appendicitis, fractures, and nonaccidental trauma were the 3 most common diagnoses that were missed or had delayed identification.Conclusions A QI initiative successfully created a pragmatic approach to identify and measure diagnostic errors by utilizing a DEI. The DEI established a framework to help guide future initiatives to reduce diagnostic errors.

Defining Diagnostic Error: A Scoping Review to Assess the Impact of the National Academies’ Report Improving Diagnosis in Health Care

“…Diagnostic error was defined as failure to establish an accurate diagnosis or failure to communicate the diagnosis in medical records, and diagnostic delay was the failure to establish a timely explanation of the patient’s health problem and communicate it in the medical records. Perry et al 33 conducted a quality improvement project to implement a methodology to identify and measure diagnostic error using the concepts of accuracy and communication across a single pediatric academic center using medical record review. The authors determined the presence of an error when there was a deviation from generally accepted performance standards, if the diagnosis could have reasonably been made based on available information at the time of presentation, and if any diagnostic uncertainty was discussed with the patient or family.…”

Identification of delayed diagnosis of paediatric appendicitis in administrative data: a multicentre retrospective validation study

“… 14 28 Although trigger tools exist to identify diagnostic errors in abdominal cases, they are too non-specific to forego the review step, which requires access to records. 29 A key advantage of our approach is that, with a high predicted probability threshold of 90%, delay can be specifically identified.…”

“…It is specifically challenging in children because most paediatric care happens outside of paediatric hospitals, where research is most commonly conducted and EHRs may not be available 14 28. Although trigger tools exist to identify diagnostic errors in abdominal cases, they are too non-specific to forego the review step, which requires access to records 29. A key advantage of our approach is that, with a high predicted probability threshold of 90%, delay can be specifically identified.…”

Under-triage: A New Trigger to Drive Quality Improvement in the Emergency Department

“…Unlike diagnostic error, which is a failure to establish an accurate and timely explanation of the patient’s health problems or communicate that explanation to the patient, medical error captures a broader framework of potential adverse outcomes, whether or not those outcomes occur. 4 , 30 This fact makes medical errors challenging to find and measure. But capturing medical error is important because early identification of faulty processes is an opportunity to avoid potentially adverse outcomes and improve patient safety.…”