Diagnostic Error & Laboratory Testing
Diagnostic error is a major patient safety concern, causing substantial harm and unnecessary medial costs. In every large organization, cases related to diagnostic error make up the largest fraction of filed claims and suits. Although the error rate is not being measured in any setting, it is estimated that 1 in 10 diagnoses is wrong, significantly delayed, or missed altogether. The root causes of diagnostic error include many system-based factors (eg breakdowns in communication, coordinating care, having expertise available when needed, supervision of trainees, etc) as well as cognitive shortcomings. The cognitive errors mostly derive from failures to synthesize the available evidence and inappropriate trust of intuition. Errors related to diagnostic testing are common, and include mistakes by the patient’s doctor (not knowing the best test to order or how to interpret it) as well as problems performing and interpreting the test results by the clinical lab or the Radiology department staff. Many interventions to reduce diagnostic error have been proposed, although few have been rigorously evaluated in clinical practice.
Originally presented on March 19, 2015 in Salt Lake City, Utah.
Mark L. Graber, MD, FACP
Senior Fellow, RTI International
Professor Emeritus of Medicine, State University of New York at Stony Brook
Dr Graber is a national leader in the field of patient safety and originated Patient Safety Awareness Week in 2002, an event now recognized internationally. He is also a pioneer in efforts to address diagnostic errors in medicine. In 2008 he originated the Diagnostic Error in Medicine conference series, in 2011 he founded the Society to Improve Diagnosis in Medicine (www.improvediagnosis.org), and this year he launched a new journal, DIAGNOSIS, devoted to improving the quality and safety of diagnosis, and reducing diagnostic error.
After this presentation, participants will be able to:
- Describe at least 3 research approaches used to estimate the incidence of diagnostic error in practice.
- Perform a root cause analysis of diagnostic error that identifies cognitive and system-related elements.
University of Utah School of Medicine, Department of Pathology, and ARUP Laboratories