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. 23% of patients experienced delayed or misdiagnosis. Among the patients who died, 6% had a diagnostic error that may have contributed to death. This study adds to a body of literature highlighting the importance of diagnostic safety within hospital medicine. We discussed the larger implications of this study with Dr. Katie Raffel in this edition of 3Q's for QI. 

Tell us about your approach to this project?

This study is a multicenter retrospective cohort study evaluating hospitalized adults who experienced ICU escalation or death with the intention of exploring diagnostic error presence, underlying causes of error and harms associated. This safety research effort required incredible collaboration and persistence with over 70 hospitalists engaged across 29 sites in order to review nearly 2500 cases. It's also worth acknowledging that this study was conducted during a challenging time for hospital medicine, the COVID-19 pandemic, further highlighting the team's resilience.

Why is this work important?

This is one of the first studies evaluating diagnostic error among this-- quite ill-- hospitalized general medicine population. We discovered that nearly 23% of patients who experience ICU escalation or death may have also experienced a delayed, missed or wrong diagnosis. Most of these diagnostic errors caused some degree of harm either temporary, permanent or resulting in death. Among just the patients who had died and were included in the study, around 6% had a diagnostic error that may have contributed to death. The most significant contributing factors were clinician assessment and diagnostic testing (ordering, performance and interpretation). 

How do you think this will impact healthcare?

Diagnostic safety has been notoriously difficult to measure, given that it often requires two provider review as gold standard. However, this study, with its time and rigor has now put a spotlight on an important safety problem in hospital medicine in this specific population. This study has already prompted further analysis of diagnosis in hospital medicine that incorporates provider/team perspective and will undoubtedly lead to further exploration of evidence-based practices to augment clinician assessment and timely/accurate test ordering, performance and interpretation. Collaboration between multiple disciplines of providers, interprofessional team members and systems will be needed to improve diagnostic accuracy among those hospitalized and experiencing high clinical acuity or decompensation. 

Read the full article in JAMA Internal Medicine here.

Check out more of Dr. Raffel's work on addressing diagnostic error:

•  Achieving diagnostic excellence through prevention and teamwork (ADEPT) study protocol: A multicenter, prospective quality and safety program to improve diagnostic processes in medical inpatients - Journal of Hospital Medicine
• Prevalence and Causes of Diagnostic Errors in Hospitalized Patients Under Investigation for COVID-19 - Journal of General Internal Medicine