Increasing Physician Reporting of Diagnostic Learning Opportunities

• Published in: Pediatrics (Evanston) Vol. 147; no. 1; p. 1
• Main Authors: Marshall, Trisha L, Ipsaro, Anna J, Le, Matthew, Sump, Courtney, Darrell, Heather, Mapes, Kathleen G, Bick, Julianne, Ferris, Sarah A, Bolser, Benjamin S, Simmons, Jeffrey M, Hagedorn, Philip A, Brady, Patrick W
• Format: Journal Article
• Language: English
• Published: United States American Academy of Pediatrics 01.01.2021
• Subjects: Diagnostic errors; Diagnostic Errors - psychology; Diagnostic Errors - statistics & numerical data; Hospitals, Pediatric - organization & administration; Hospitals, Pediatric - standards; Humans; Incident reporting (Medical care); Learning; Medical diagnosis; Medical errors; Methods; Ohio; Outcome and Process Assessment, Health Care; Patient admissions; Patient Safety - standards; Patients; Pediatrics; Physicians; Physicians - organization & administration; Physicians - psychology; Physicians - standards; Professional education; Quality control; Quality Improvement - organization & administration; Training; Truth Disclosure; Ohio; United States
• ISSN: 0031-4005; 1098-4275
• DOI: 10.1542/PEDS.2019-2400

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. Our improvement team used 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 2-reviewer process. 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 multifactorial after formal review. We used quality improvement methodology, focusing on psychological safety, to increase physician reporting of DLOs. This growing data set has generated nuanced learnings that will guide future improvement work.