159 - The Pursuit of Learning and Exploring Diagnostic Excellence at an Academic Children’s Hospital

Publication Number: 3153.159

Erin Aldag, University of Utah School of Medicine, Salt Lake City, UT, United States; Lee Morris, University of Utah School of Medicine, Salt Lake City, UT, United States; Kevin Chen, University of Utah, salt lake City, UT, United States; Jonathan Sawicki, University of Utah School of Medicine, Salt Lake City, UT, United States

Background: Diagnostic errors in medicine are associated with patient safety events and have potential for great harm. It is important for healthcare organizations to have programs in place to monitor the diagnostic process and identify, learn from, and reduce diagnostic errors. At Primary Children's Hospital (PCH), diagnostic errors were identified as a contributor to high-harm safety events (HHE), but no institutional infrastructure was in place to improve diagnosis.

Objective: We designed and implemented a Diagnostic Excellence Program (DEP) at a free-standing children's hospital to decrease the frequency of HHEs related to delayed diagnosis.

Design/Methods: The project team conducted a literature review to understand the state of diagnostic safety science, met with national experts to identify key components, and created a program driver diagram (Figure 1). Program initiatives were implemented over an 18-month period starting in January 2024. Statistical process control charts were used to examine the impact of the program on the frequency of HHEs related to delayed diagnosis.

Results: Our DEP centers on the review of HHEs using the Safer Dx Instrument and the Diagnostic Error Evaluation and Research Taxonomy (Figure 2). The results of these reviews are utilized in three arms of the DEP: patient safety, quality improvement, and education. Results of event reviews are summarized in "Diagnosis Fishbone" diagrams which are incorporated into our institution's interdisciplinary root cause analysis meetings. The results prompted creation of clinical tools focused on improving communication between members of the diagnostic team. We implemented a biannual Clinical Reasoning Grand Rounds session and a longitudinal curriculum for pediatric residents to highlight the lessons learned from the event reviews. Following the DEP's implementation, the days between HHEs related to delayed diagnosis have increased from a baseline mean of 4.3 to 10 (P <.001) (Figure 3).

Conclusion(s): We designed and implemented a DEP that combines patient safety, quality improvement, and education initiatives. As a result, we observed a decrease in the frequency of HHEs related to delayed diagnosis. Our DEP can be used as a simple, practical guide for other institutions aiming to pursue learning and exploring diagnostic excellence.

Figure 3. Days between high-harm safety events
Days between high-harm safety events measured over 18 months with implementation of DEP components.

Figure 1. Program Driver Diagram
Driver diagram created by DEP project team to identify opportunities for improvement and project development.

Figure 2. Most common diagnostic process failure points
Review of approximately 100 high harm safety event cases related to delay in diagnosis or treatment as categorized by Diagnosis Error Evaluation and Research (DEER) Taxonomy.