Issue link: https://viewer.e-digitaledition.com/i/1111492
How Healthcare Organizations Can Use Team-Based Care and More Efficient Processes to Reduce Diagnostic Errors BY THOMAS CROCKER DIAGNOSTIC ERRORS POSE A SIGNIFICANT THRE AT TO PATIENT SAFE T Y AND CAN ERODE TRUST IN PROVIDERS, WHICH MAY DAMAGE ORGANIZ ATIONAL REPUTATIONS AND HURT RE VENUE. MEDICAL PR ACTICES AND HE ALTHCARE SYSTEMS CAN PRE VENT A LE ADING CAUSE OF DIAGNOSTIC ERRORS — FOLLOW-UP SYSTEM FAILURES — BY ADOPTING A TE AM APPROACH TO THE DIAGNOSTIC PROCESS AND OPTIMIZING WORKFLOWS. DI AGNOS TIC ERROR S — inaccurate diagnoses or diagnoses that healthcare teams do not communicate to patients or fail to convey in a timely or coherent manner — are a pervasive problem in health care, regardless of venue. When Constellation, a Minneapolis-based col- lective of medical professional liability insurers and hea lth service partners, a na lyzed ma lpractice cla ims from a variety of healthcare settings, it found diagnostic errors were the third-most- common reason for claims, accounting for more total incurred costs than any other cause. A breakdown of where diag- nostic errors occurred reveals they were especially common beyond hospital walls: + 57 percent of diagnosis-related mal- practice claims arose from outpatient care settings + 2 6 p e r c e nt or i g i n a t e d i n e m e r - gency departments + 17 p er c ent s t em me d f r om i npa- tient environments "Diagnostic errors are widespread in outpatient care because there are a variety of systems that involve many different individuals in those settings," says Traci Poore, JD, CPHR M, Senior Risk a nd Patient Safety Consultant at medica l professional liability insurance provider MMIC, which is part of the Constellation family. "Often, these errors do not arise from clinical steps or judgment, but from failure to obtain or communicate results. Essentially, the systems break down." Those are follow-up systems — the processes hea lt hca re orga nizations theoretically follow to ensure timely com- munication of diagnostic information to patients and coordinate care. In practice, however, those systems often fail. In the Constellation ana lysis, 52 percent of diagnosis-related malpractice claims from outpatient settings featured a follow- up system failure. What does a follow-up system failure look like? Kassie Remo, MH A , PMP, FACMPE, CPHQ, Director of Health Care at CliftonLarsonAllen LLP, a national hea lthcare professiona l services firm that collaborates with Constellation, offers the example of a female patient who visits her OB-GYN's office for a wellness exam that includes a pap smear. "The results of the pap smear are abnor- mal, which warrants performing another within a certain time period," Remo says. "If no system is in place to ensure an additional test is obtained, it could be a year before the patient returns to the clinic, and then a provider looking up the patient's record may recognize a test is missing and wonders whether it took place. Often, in cases like this one, patients don't follow through with additional tests because they don't understand what steps they need to take." 2 4 2 4❱❱❱❱❱ S P E C I A L F E A T U R E