Diagnostic errors (DE) are a critical but understudied cause of preventable patient harm. While much work has focused on examining the incidence and factors contributing to DEs in ambulatory and emergency room settings, fewer studies have examined the incidence of DEs in hospitals or how they contribute to adverse events during the hospital encounter. IHQSE Faculty, Dr. Katie Raffel, along with other experts on diagnostic error, led an AHRQ-funded study at 31 US hospitals aimed at defining the prevalence and underlying causes of DEs in patients who die in the hospital or are transferred to the ICU after the first 48 hours.

Physical therapy (PT) in inpatient settings is a limited and valuable resource. Inappropriate PT consultation is costly and can lead to delays in care and discharge planning. A team of IHQSE alumni, including faculty members, Dr. Emily Gottenborg and Dr. Moksha Patel, dug into the root causes of unnecessary PT consultations and deployed an intervention that reduced the rate of inappropriate PT consults to less than 10%.

Diagnostic error is common, morbid, and mortal. IHQSE faculty member, Dr. Katie Raffel, along with Dr. Andrew Auerbach and other experts on diagnostic error, recently published findings from a multicenter retrospective cohort study in which 2500 hospitalized adults who experienced ICU escalation or death were evaluated for diagnostic error. This study adds to a body of literature highlighting the importance of diagnostic safety within hospital medicine.

The early COVID-19 pandemic created substantial disruption to healthcare delivery, including changes to diagnostic processes. In this 8-center retrospective cohort study of diagnostic error among patients hospitalized with possible COVID-19, IHQSE Faculty Member Dr. Katie Raffel found that 14% of the 257 patients included experienced delayed, missed or wrong diagnosis, 1/3 of which may have led to harm. Unexpectedly, diagnostic process faults related to policies/procedures related to COVID-19 suspicion itself (such as need for isolation or medical distancing) were not independently associated with error. Instead, diagnostic process faults related to clinical assessment and test ordering/interpretation remained most prominent, similar to other studies of the diagnostic process.