Closing the Loop: An Opportunity to Reduce Diagnostic Error

Paul L. Epner, MBA, M.Ed., CEO, Society to Improve Diagnosis in Medicine

Diagnostic errors are the most common, most catastrophic, and most costly of all medical errors. Every year in the United
States, 12 million adults are impacted in outpatient settings alone by delayed or inaccurate diagnoses. Approximately
250,000 harmful diagnostic errors are associated with hospitalized patients annually, and estimates of premature deaths in all settings are in excess of 300,000. Diagnostic error is the number-one cause of malpractice claims and is estimated to add $100 billion in unnecessary costs to the healthcare system each year. And if these statistics aren’t enough to motivate addressing the problem, consider this: an inaccurate or delayed diagnosis is likely to lead to treatments or additional procedures that will be wasteful or harmful, while the real underlying disease progresses unchecked.

Improving diagnostic quality is not simple. Diagnosis, by its very nature, involves uncertainty. And there can be great heterogeneity in how different
patients with the same problems present. Even pertaining to a single patient, presentation can vary over the course of the problem and lead
to diagnostic pitfalls.

Research into malpractices cases involving serious harm find that on average, there are more than three contributing factors to each case. With no consensus standards on measuring diagnostic error—or even on documenting diagnostic-safety events—prioritizing and addressing sources of error locally can be challenging. However, as the National Academy of Medicine asserts, “Improving the diagnostic process is not only possible, but it also represents a moral, professional, and public health imperative.” And despite the complexities, there are immediate opportunities for improvement. For example, many diagnostic errors are caused by failure or delays in closing the loop (CTL) on specific processes, such as test ordering and result interpretation followed by patient communication. Similar issues exist with initiating,completing,and communicating the results of specialty referrals.

CTL has been studied and well described in the literature. There are a variety of reasons that test results do not receive timely and effective follow-up, including transitions from inpatient to outpatient status, secondary or incidental findings that are not sufficiently prominent in reports or appreciated by the ordering clinician,limitations on the designation of critical value and its reporting imperatives,split order result availability (especially associated with “send-outs”), and failure to incorporate findings of specialty physicians into primary-care records.

In this issue of The Physicians Report, we’ll take a closer look at this important opportunity to make a difference. In the area of diagnostic quality, there’s not much low-hanging fruit, but closing the loop is as close to that as possible. Readers are encouraged to seize that opportunity—their patients will be thankful for it.