Reducing diagnostic error
Diagnostic errors often result from a combination of cognitive and system factors, but addressing even one can help prevent harm.
Sunday, 23 March 2025
Quick guide
- Diagnostic errors are often the result of multiple contributing factors and compounding mistakes.
- Different strategies can be used to help mitigate specific errors in the diagnostic process.
- Preventing even one contributing factor can help prevent a diagnostic error and adverse event.
Causes of diagnostic errors
Diagnostic errors are often the result of multiple contributing factors and compounding mistakes. The Swiss cheese model is an accurate analogy. Each step in the diagnostic process has potential vulnerabilities (holes in the Swiss cheese). An error in a single step may not affect the outcome, but compounded errors can align to cause diagnostic failure. Removing even one contributing factor can prevent errors from leading to a diagnostic failure.
While errors often have multiple contributing factors, classifying errors into broad groups can help prevent them.
- Cognitive errors: Doctor errors during the diagnostic process. Cognitive errors include failures in receiving, understanding or processing critical information, and biases. It also includes knowledge deficits, failure to apply knowledge, context failure, heuristics and communication errors.
- System errors: Errors due to system failures, which cover training, environment, technology, communication or processes and follow-up processes. System factors may overlap with and contribute to cognitive errors.
Key strategies to mitigate cognitive errors
Differential diagnosis
A thorough differential diagnosis process is crucial. Always consider various conditions that could explain the patient's symptoms. Asking critical questions such as "What else could explain the symptoms?" or "What are the consequences for the patient if I am wrong?" can help you avoid cognitive shortcuts and ensure comprehensive evaluation. This approach mitigates the risk of several heuristics, including confirmation bias and diagnosis momentum.
Second Opinions
Seeking a second opinion from another experienced colleague when faced with diagnostic challenges or complex cases can provide a fresh perspective, uncover overlooked possibilities, and validate or refine your initial diagnosis. This practice is essential for avoiding cognitive biases and ensuring optimal patient care.
Diagnostic Time-Outs
Incorporating diagnostic time-outs into your clinical practice involves pausing to critically evaluate your differential diagnosis. This deliberate pause allows you to reflect on initial diagnostic impressions, consider alternative explanations for the patient's symptoms, and identify potential cognitive biases.
Not Yet Diagnosed (NYD)
Embracing the concept of 'Not Yet Diagnosed' (NYD) involves recognising and accepting diagnostic uncertainty. Adopting a mindset that embraces uncertainty and remaining open to revising the differential diagnosis as new information becomes available can help you avoid premature closure and foster a comprehensive understanding of the patient's clinical presentation.
Clinical Decision-Making Tools
Using clinical decision support tools, such as computerised alerts, clinical guidelines, and diagnostic support systems, can aid you in making accurate diagnoses. These tools provide valuable information and reminders that can guide your diagnostic process.
Communication and Collaboration
Effective communication with your patients is crucial for gathering complete histories and aligning diagnostic goals. Clearly communicating any diagnostic uncertainty to patients and colleagues helps ensure continuity of care and builds trust. Establishing open communication channels fosters a collaborative environment and encourages comprehensive information exchange.
Checklists
Implementing checklists can optimise your cognitive approach to diagnostics. General checklists prompt you to consider all possibilities, differential diagnosis checklists help you avoid common diagnostic errors, and specific disease checklists improve the evaluation of selected conditions. Using checklists reduces reliance on memory and intuition, enhancing diagnostic accuracy.
System factor mitigations
Improving Communication Practices
Standardised communication protocols, such as iSoBAR, enhance the clarity and effectiveness of information exchange during handovers. Regular interdisciplinary meetings facilitate collaboration among interdisciplinary teams, improving the overall diagnostic process.
Enhancing Coordination of Care
Establishing care coordination teams or case management systems ensures seamless transitions of care between different healthcare settings and providers. Implementing interoperable electronic health record (EHR) systems facilitates information sharing and continuity of care.
Supervision and Oversight
Structured supervision processes, such as peer reviews and case conferences, provide feedback and oversight of your diagnostic decision-making. Incorporating double-check procedures for critical diagnostic tests can minimise errors due to individual oversight.
Optimising Technology and Work Environment
Adopting user-friendly technology solutions, such as decision support tools and electronic clinical pathways, can help you make accurate and timely diagnoses. Designing ergonomic healthcare workspaces can minimise distractions, which can support cognitive processes and reduce errors.
Resource Allocation
Ensuring adequate staffing levels and resources, and supporting timely access to diagnostic tests, consultations, and treatments, can reduce reliance on mental shortcuts and minimise cognitive errors. Effective workload management strategies, such as team-based care models and task delegation, help prevent clinician burnout and ensure comprehensive diagnostic evaluations.
Feedback Mechanisms
Creating mechanisms for timely feedback on your diagnostic performance, such as peer reviews, audit and feedback programs, and clinical performance dashboards, helps you learn from your diagnostic errors and improve your practice. Fostering a culture of open communication and psychological safety encourages you to discuss diagnostic errors without fear of retribution.
Learning and Improvement Culture
Providing educational opportunities and training programs focused on diagnostic reasoning, critical thinking, and error prevention strategies for healthcare providers at all levels enhances overall diagnostic accuracy.
Embracing Artificial Intelligence (AI)
The integration of AI in healthcare offers significant potential for enhancing diagnostic accuracy and efficiency. However, it is essential to ensure AI systems comply with privacy regulations to protect patient data. AI should complement, not replace, your clinical judgment and expertise.
Summary
By implementing these strategies, you can significantly reduce the risk of diagnostic errors, ensuring better patient outcomes and enhancing the overall quality of healthcare delivery.
Additional resources
Avant factsheet: Missed or delayed diagnosis
More information
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IMPORTANT: This publication is not comprehensive and does not constitute legal or medical advice. You should seek legal or other professional advice before relying on any content, and practise proper clinical decision making with regard to the individual circumstances. Persons implementing any recommendations contained in this publication must exercise their own independent skill or judgement or seek appropriate professional advice relevant to their own particular practice. Compliance with any recommendations will not in any way guarantee discharge of the duty of care owed to patients and others coming into contact with the health professional or practice. Avant is not responsible to you or anyone else for any loss suffered in connection with the use of this information. Information is only current at the date initially published.
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