TOP 59 - Implementation of a Diagnostic Uncertainty Checklist During Family Centered Rounds

Publication Number: 2811.TOP 59

Abby E. Halm, University of Utah, Salt Lake City, UT, United States; Maria Vigil-Mallette, University of Utah School of Medicine, Salt Lake City, UT, United States; Maya Wheeler, University of Utah School of Medicine, Salt Lake City, UT, United States; Erin Aldag, University of Utah School of Medicine, Salt Lake City, UT, United States; Kevin Chen, University of Utah, sale lake City, VT, United States; Jonathan Sawicki, University of Utah School of Medicine, Salt Lake City, UT, United States

Background: Diagnostic error at our institution is one of the top contributors to the highest harm safety events. There is theoretical evidence to suggest that interventions designed to improve clinicians' cognitive processes and ability to communicate diagnostic uncertainty may help to mitigate diagnostic error, however, the evidence base in actual clinical practice is limited.

Objective: We aimed to implement diagnostic communication tools on pediatric hospital medicine (PHM) teams to increase the mean number of days between high harm safety events related to delayed diagnosis (Dx-HHEs) from 16.5 to 24 by January 1, 2026.

Design/Methods: We created a driver diagram (Figure 1) and identified two change ideas: (1) a structured diagnostic handoff between the emergency department (ED) and PHM team and (2) a diagnostic uncertainty checklist to be used during PHM family centered rounds (FCR).

Through direct observation and interviews with key stakeholders we created a process map based on the SEIPS model to outline the flow of patient information from the ED to PHM teams. Residents received training on implementing a diagnostic uncertainty label for patients admitted from the ED in written handoffs. However, due to electronic medical record limitations, we were unable to fully implement a communication tool during this time point.

We utilized a literature review and input from key stakeholders to design a diagnostic uncertainty checklist to be used on FCR. We defined our outcome measure as the number of days between Dx-HHEs identified in our institution's incident reporting system. We created and distributed electronic surveys to ascertain the percent usage of the intervention, provider perceptions of the intervention's impact on communication and differential diagnosis generation, and the perceived amount of time it took to use the intervention.

To date, the median percent usage of the checklist on a weekly basis is 83% with the majority of residents and PHM attendings perceiving the checklist as a useful tool which helps to improve communication (Table 1). While we have not detected special cause variation in our outcome measure, the mean number of days between Dx-HHEs has increased from a baseline of 16.5 to 29.4 (Figure 2). We plan to complete data collection by January 1, 2026, and analysis by January 31, 2026. We plan to focus future work on better incorporating the patient and family's perception of diagnostic uncertainty into FCR. Our institution's IRB determined this project to be non-human subject's research.

Figure 1: Driver Diagram


Table 1: Attending and Resident Reactions to the Diagnostic Uncertainty Checklist


Figure 2: Days Between Dx-HHEs on PHM Teams
CL, center line; Dx-HHE: high harm event related to a delay in diagnosis; LCL, lower control limit; PHM, pediatric hospital medicine; UCL, upper control limit