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Diagnostic Learning Opportunities: Increasing Physician Reporting of Suspected Diagnostic Errors

Marshall, Trisha L, M.D.
http://orcid.org/0000-0002-2492-3147
http://rave.ohiolink.edu/etdc/view?acc_num=ucin1592171499312483

Abstract Details

2020, MS, University of Cincinnati, Medicine: Clinical and Translational Research.
Background: An estimated 10% of Americans experience a diagnostic error annually, yet little is known about pediatric diagnostic errors. Physician reporting is a promising method for identifying diagnostic errors. However, our pediatric hospital medicine (PHM) division had only 1 diagnostic-related safety report in the preceding 4 years. We aimed to improve attending physician reporting of suspected diagnostic errors from 0 to 2 per 100 PHM patient admissions within 6 months. Methods: Our improvement team utilized the Model for Improvement, targeting the PHM service. To promote a safe reporting culture, we used the term Diagnostic Learning Opportunity (DLO) rather than diagnostic error, defined as a “potential opportunity to make a better or more timely diagnosis.” We developed an electronic reporting form and encouraged its use through reminders, scheduled reflection time, and monthly progress reports. The outcome measure, the number of DLO reports per 100 patient admissions, was tracked on an annotated control chart to assess the effect of our interventions over time. We evaluated DLOs using a formal two-reviewer process. Results: Over the course of 13 weeks there was an increase in the number of reports filed from 0 to 1.6 per 100 patient admissions, which met special cause variation, and was subsequently sustained. Most events (66%) were true diagnostic errors and were found to be multi-factorial upon formal review. Conclusions: We utilized quality improvement methodology, focusing on psychological safety, to increase physician reporting of DLOs. This growing data set has generated nuanced learnings which will guide future improvement work.
Patrick Ryan, Ph.D. (Committee Chair)
Patrick Brady, M.D. (Committee Member)
Philip Hagedorn (Committee Member)
30 p.
Surgery
Diagnostic Error; Quality Improvement; Patient Safety; Pediatric Hospital Medicine

Recommended Citations

Citations

  • Marshall, M.D., T. L. (2020). Diagnostic Learning Opportunities: Increasing Physician Reporting of Suspected Diagnostic Errors [Master's thesis, University of Cincinnati]. OhioLINK Electronic Theses and Dissertations Center. http://rave.ohiolink.edu/etdc/view?acc_num=ucin1592171499312483

    APA Style (7th edition)

  • Marshall, M.D., Trisha. Diagnostic Learning Opportunities: Increasing Physician Reporting of Suspected Diagnostic Errors. 2020. University of Cincinnati, Master's thesis. OhioLINK Electronic Theses and Dissertations Center, http://rave.ohiolink.edu/etdc/view?acc_num=ucin1592171499312483.

    MLA Style (8th edition)

  • Marshall, M.D., Trisha. "Diagnostic Learning Opportunities: Increasing Physician Reporting of Suspected Diagnostic Errors." Master's thesis, University of Cincinnati, 2020. http://rave.ohiolink.edu/etdc/view?acc_num=ucin1592171499312483

    Chicago Manual of Style (17th edition)

ucin1592171499312483
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This open access ETD is published by University of Cincinnati and OhioLINK.