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Quality Manager formerly known as abaqis®

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An Important ER Missed Diagnosis Example and Looking for Solutions to Them

April 1st, 2021
April 1st, 2021

Missed ER diagnoses can have a huge impact on the organizations where they occur. This blog post is the first of several based on a recent HealthStream webinar, “Missed Diagnosis in the ER: The Silent Tragedy.”

Here’s a real-life example of a missed diagnosis and what happened as a result. Texas Health Presbyterian Hospital in Dallas had a dire event happen in the ER in September 2014. A gentleman presented to the ER at Texas Health with an elevated fever of over 103 degrees, as well as a documented travel history to Liberia, which was then an area rampant with Ebola. He was discharged hours later with the diagnosis of sinusitis.

Two weeks later this patient died, and other healthcare workers in the organization were diagnosed with the disease. An independent panel identified poor communication in the ER, poor configuration of the EMR, and a diminished focus on patient safety as the three leading causes of this event. What did this event cause the organization? Two staff members contracted the virus and later sued the organization for an undisclosed amount of money. Clinical volumes in the emergency department went down 50%. As a financial impact, net revenue went down 8.1 million dollars. Then, there’s the damage to the organization’s reputation. Missed diagnoses may not always occur on this grand of a scale; however, they do occur and they can be just as impactful.

The Regulatory and Accrediting Body Response

The Joint Commission has said that diagnostic errors are a major source of preventable patient harm, and they have been implicated in a large percentage of adverse events and malpractice. The Joint Commission standards list diagnoses a minimum of 43 times in their hospital manual. How important do you think this topic is to them?

National organizations such as the Agency for Healthcare Research and Quality (AHRQ) and the National Patient Safety Foundation (NPSF) have identified reducing diagnostic errors as a top priority. They’re already developing toolkits for organizations to implement to help reduce these errors, whether it be from an educational perspective, a checklist that you can put on your EMRs, EMR banners, different things. There’s a whole list of things in their toolkits that they are putting out for people to use to help attack this problem.

A National Academies of Science, Engineering, and Medicine (NASEM) report has also provided recommendations. They have come up with recommendations about how we could start defending ourselves against this problem. Solutions involve education and patient communication, including clinical reasoning, teamwork, inter-professional practice, communication, use of appropriate testing, etc.

Another recommendation is for the Office of National Coordinators for Health Information (ONC) to have oversight and regulation of healthcare IT vendors. Oversight should include the provision of workflows and free exchanges amongst organizations. Accreditation organizations are going to insist on monitoring. They’re also going to want reporting, and more core measures. They’ll be focused on the questions: When do things do occur, what are we doing about it? How deep are we going into that evaluation of what went wrong?

Ongoing Training

Importantly, they want us to provide ongoing training. That means we need to have policies and procedures that promote a non-punitive culture for this and also develop a work system in which the processes occur in a positive way.

Voluntary Reporting and CMS Evaluations

AHRQ and other appropriate agencies should encourage voluntary reporting of diagnostic errors. Mechanisms for voluntary reporting are currently being developed. Professional liability insurance carriers and captive insurers should collaborate with healthcare professionals through education, training, and practice improvement approaches and encourage participation in programs. CMS and other payers should assess the impact of payment and care delivery models on diagnostic process and occurrence.

Watch the full webinar recording.


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