Overcoming Systemic Challenges to Reduce Diagnostic Errors

Medical Errors are a leading cause of death in the United States, causing preventable harm to around 400,000 Americans annually, at a cost of approximately $20 billion per year.

In "Preventing Medical Injury," published in the Quality Review Bulletin, researchers define four types of medical errors: diagnostic errors, including missed or delayed diagnosis; treatment errors, which include medication mistakes; preventative errors, or the failure to provide protective monitoring or care; and other errors, which include communication failures.

As part of its efforts to support higher quality and safety standards in healthcare, the Washington State Hospital Association (WSHA) performs ongoing work to discover the root causes of diagnostic errors, which may occur in up to 15% of medical diagnoses, according to Johns Hopkins Medicine. When the causes of diagnostic error are examined, some clear patterns emerge, says Trish Anderson, WSHA’s senior director of safety and quality.

“Some of the many causes of diagnostic error that we’ve been able to identify throughout healthcare settings are episodic care and limitations to clinical assessment, which affect subsequent decision-making,” says Anderson. “Additionally,there can be a lack of time for sufficient communication between patients and providers and between clinicians.” By addressing these core contributors to diagnostic error, organizations can make progress toward closing the loop.

Miscommunication between providers is a leading cause of diagnostic errors, particularly during shift changes when caregivers hand off medical information about patients to other providers.According to Stanford Medicine research, shorter shifts for medical residents are increasing such handoffs, along with the risk for preventable errors.

“Communication is where it really falls apart,” says Ian Doten, MD, a Seattle-based emergency-department physician and Medical Director at InSytu Advanced Healthcare Simulation.“You can have a spotless process with a beautiful checklist, but are you communicating well with the nurse or with the patient in terms of what needs to be done next?”

Replacing face-to-face communication between providers and staff with digital data stored in electronic health records (EHRs) won’t solve systemic communication problems, notes Doten,who previously served as Chief of Emergency Medicine at Swedish Medical Center in Seattle. “I think electronic health records make some communication easier, but sometimes it’s not effective because the signal-to-noise ratio is off; the piece of information that I need from the patient’s medical history is in the EHR, but so is all of this additional information. If I’m in the emergency department with a patient and there are two pieces of medical information I need to make a decision, that information can easily get buried in the data.”

Overcoming Systemic Challenges boxed quote 1

Reducing communication lapses in medical settings remains a persistent challenge, in part because communication styles and preferences vary from person to person, says Ben Wandtke, MD, BMS, Vice Chair,Quality and Safety, and Chief of Diagnostic Imaging at FF Thompson Health in Canandaigua, New York. In his study “Reducing Delay in Diagnosis: Multistage Recommendation Tracking,” published in the American Journal of Roentgenology, multiple communication interventions were assessed to determine the most effective ways to communicate with patients and providers about recommended follow-up care. “When we worked with patients, we found that they have variable preferences in how they want to be communicated with, so there’s not one communication method that works for everyone,” he says. Rather than relying on a single communication touchpoint—for example, communicating with patients about follow-up care via an electronic patient portal—Wandtke found that establishing a series of different types of communication interventions—including letters, phone calls, and reminders from primary care providers—was most effective for closing the loop.


Improving team communication through the creation of small work groups, teaching teamwork behaviors and
skills, and developing communication habits for teams can help reduce communication-related errors,according to research supported by the U.S. Army. In their study of emergency department malpractice incidents at eight hospitals, published in the Annals of Emergency Medicine, researchers judged more than half of the deaths or permanent injuries to be preventable through improved teamwork. The study found an average of 8.8 teamwork failures per care episode.

Collaborative goal-setting is another strategy that’s been shown to improve communication between patients and providers and reduce the likelihood of inaccurately reported medical information. In this model, patients work with their providers to monitor and report their progress toward personal health goals.

The risk for medical errors doesn’t end when patients leave the hospital or clinic. In fact, more than half of medical errors take place outside of a clinical setting. Research shows that the risk for medical error increases significantly after hospital discharge or episodic care: a study published in the Annals of Internal Medicine found that more than 50% of hospital patients experienced a clinically significant medication error within 30 days of discharge.

Disjointed or nonexistent communication between the many providers involved in a patient’s hospital care contribute to the risk for medical error, particularly diagnostic errors and treatment errors, during care transitions, says Wandtke. “There may be two or three hospitalists making recommendations for follow-up care, but only one puts in discharge instructions for the patient,” he says. “So there are inherent risks in the transition of care from hospital care to outpatient care, and hospital offices are not equipped with resources to provide appropriate safety nets to engage a high reliability approach to their healthcare.”


Patient-centered approaches to error reduction are the key to reducing medical errors, according to a study published in Australian Prescriber. Actively involving the patient in discharge planning and doublechecking prescription-medication instructions after each episode of care can reduce the risk of medication errors and adverse drug events. “Our health system needs to keep an eye on these patients,” notes Wandtke. “It is really a chain of communication, and it can break at any point in the process.”


Electronic health records (EHRs) can support more accurate medical diagnoses, create efficiencies, and improve communication. But while information technology may support patient safety in some instances, it has also been shown to contribute to medical errors. According to research published in the Journal of the American Medical Informatics Association (JAMIA), healthcare information technology can have unintended consequences that contribute to diagnostic errors, from disrupting existing communication processes, to offering flawed decision support, to overburdening providers with tiring data-entry responsibilities.

“Electronic health records were built for billing, not for patient care,” says Doten. “The challenge is designing tools that provide meaningful, real-time information. With healthcare, especially in the emergency room with a patient in cardiac arrest, a lot of the meaningful communication is in real time.”

While EHRs can support early diagnosis by flagging certain patients for recommended cancer screenings, other patients are easily missed. “EHRs have been successful at identifying patients for breast-cancer screening and colon cancer screening, because it’s very easy to find patients in the system who are the right age and gender for screening,” says Wandtke. “For lung cancer, it hasn’t been as easy, because it’s harder to identify a patient’s smoking history in an EHR. As a result, there has been slow uptake and low participation [in lung-cancer screening] without adequate tools in the EHR. We know that about 5% of eligible patients are receiving their screening for lung cancer, and that is concerning.”

The JAMIA researchers focus their discussion on latent or silent medical errors that result from a mismatch between the function of the information-technology system and the day-to-day demands of healthcare work.This mismatch contributes to two main categories of errors that organizations must address to effectively improve quality and safety: errors in the process of entering and retrieving information,and errors in the communication and coordination processes the system is designed to support. Information technology systems must address these two main categories of errors to facilitate safer care.

Involving the EHR’s end users—doctors, nurses, and other key personnel—in the system’s design and implementation can facilitate a better match between the system and the needs of its users.“As medicine gets more complex, we need to make sure it works for the end user,” says Doten. “The people closest to the work should design the work. You can set goals as an organization, but what’s meaningful is how you actually execute them when you get down to the doctors and nurses.”

The COVID-19 pandemic is likely to increase rates of diagnostic errors for several reasons, according to 2020 research from the Society of Hospital Medicine. Early in the pandemic,rapidly evolving diagnostic information for COVID-19 made missed or delayed diagnosis more likely. Situational factors including staffing shortages, staff fatigue and burnout, and the utilization of newly designed work processes have also increased the risk for medical error during the COVID-19 era.

“Very early on in the COVID journey, there was robust discussion among providers and hospital leadership to understand the potential of missing or delaying a COVID diagnosis,” says Anderson. “COVID-19 can look like many other health conditions; this also increases risk for patients and providers. As testing became available, we saw the importance of being able to quickly put into play many precautions, like isolation and home quarantine, along with the importance of the ability to quickly rule out other conditions.”

“COVID has exposed everything that is not well with the healthcare system,from access to care and capacity issues to the need for telehealth,” says Doten.“The healthcare system did an amazing job, but because everything was so acutely cobbled together, we’re going to have to figure out how to implement it thoughtfully going forward.”

Overcoming Systemic Challenges boxed quote 2

The Society of Hospital Medicine researchers recommend systemic interventions to reduce the risk of medical error during the COVID-19 pandemic. Importantly, error-reduction strategies should begin with people-focused interventions for improving communication between clinicians.Routine “diagnostic huddles” between providers and staff can facilitate the
exchange of vital diagnostic information about patients, even in a busy clinical setting. According to research published in the Annals of Internal Medicine, healthcare organizations can help providers and staff cope with COVID-related stress by facilitating peer support and establishing and providing training to the team, following a clear crisis-communication plan.

Any worthwhile effort to reduce medical errors must include an examination of an organization’s culture, says Doten.
“We need to create a culture where we can openly talk about errors, and where learning from our mistakes is possible,”
he says. “Changing culture is hard. We need everyone to feel safe speaking up and ensure that those kinds of things are encouraged, not punished or viewed in a negative way. In my lifetime of practice, I’ve seen a pretty big swing in that direction, and that’s huge.”

For more information about “Just Culture,” see “A Just Culture: Reducing Errors and Clearing the Way for Improvements” on the Physicians Insurance website (phyins.com).