National Academies Press: OpenBook

Improving Diagnosis in Health Care (2015)

Chapter: Appendix C: Previous Diagnostic Error Frameworks

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Suggested Citation:"Appendix C: Previous Diagnostic Error Frameworks." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Diagnosis in Health Care. Washington, DC: The National Academies Press. doi: 10.17226/21794.
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Suggested Citation:"Appendix C: Previous Diagnostic Error Frameworks." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Diagnosis in Health Care. Washington, DC: The National Academies Press. doi: 10.17226/21794.
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FIGURE C-1 Venn diagram illustrating relationships between errors in the diagnostic process; missed, delayed, or wrong diagnoses; and adverse patient outcomes. Group A represents adverse outcomes resulting from error-related misdiagnosis (pathology specimens erroneously mixed up [diagnostic process error], resulting in wrong patient being given diagnosis of cancer [misdiagnosis] who then undergoes surgery with adverse outcome [adverse event]). Group B represents delayed diagnoses or misdiagnoses due to process error (positive urine culture overlooked, thus a urinary tract infection is not diagnosed but patient has no symptoms or adverse consequences). Group C represents adverse events due to misdiagnoses but no identifiable process error (death from acute myocardial infarction but no chest pain or other symptoms that were missed).
SOURCES: Adapted from Schiff et al., 2005, and Schiff and Leape, 2012.

Suggested Citation:"Appendix C: Previous Diagnostic Error Frameworks." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Diagnosis in Health Care. Washington, DC: The National Academies Press. doi: 10.17226/21794.
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FIGURE C-2 Singh’s diagnostic error framework, which employs the term “missed opportunity” to imply “that something different could have been done to make the correct diagnosis earlier.”
SOURCE: Singh, 2014. © Joint Commission Resources: Joint Commission Journal on Quality and Patient Safety. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations (2014), 40(3), (100). Figure. Reprinted with permission.

Suggested Citation:"Appendix C: Previous Diagnostic Error Frameworks." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Diagnosis in Health Care. Washington, DC: The National Academies Press. doi: 10.17226/21794.
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FIGURE C-3 Singh and Sittig’s diagnostic error framework, which illustrates the sociotechnical system in which diagnosis occurs and opportunities to measure and learn from diagnostic errors to improve diagnosis and patient and system outcomes.
NOTE: * Includes eight technological and non-technological dimensions.
SOURCE: Reproduced from BMJ Quality and Safety, H. Singh and D. F. Sittig, 24(2), 103–110, 2015 with permission from BMJ Publishing Group Limited.

Suggested Citation:"Appendix C: Previous Diagnostic Error Frameworks." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Diagnosis in Health Care. Washington, DC: The National Academies Press. doi: 10.17226/21794.
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images

FIGURE C-4 Newman-Toker’s diagnostic error framework, which defines preventable diagnostic error as the overlap between diagnostic process failures and diagnostic label failures.
SOURCE: Reprinted, with permission, from David Newman-Toker, A unified conceptual model for diagnostic errors: Underdiagnosis, overdiagnosis, and misdiagnosis; in Diagnosis 1(1), 2014, pp. 43–48.

Suggested Citation:"Appendix C: Previous Diagnostic Error Frameworks." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Diagnosis in Health Care. Washington, DC: The National Academies Press. doi: 10.17226/21794.
×

images

FIGURE C-5 Newman-Toker’s diagnostic error framework, including suboptimal diagnostic process and optimal diagnostic process, as well as reducible and unavoidable diagnostic error.
NOTE: * “Near misses” and harm from overtesting and overdiagnosis also result from suboptimal diagnostic processes.
SOURCE: Reprinted, with permission, from David Newman-Toker, A unified conceptual model for diagnostic errors: Underdiagnosis, overdiagnosis, and misdiagnosis; in Diagnosis 1(1), 2014, pp. 43–48.

Suggested Citation:"Appendix C: Previous Diagnostic Error Frameworks." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Diagnosis in Health Care. Washington, DC: The National Academies Press. doi: 10.17226/21794.
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REFERENCES

Newman-Toker, D. E. 2014. A unified conceptual model for diagnostic errors: Underdiagnosis, overdiagnosis, and misdiagnosis. Diagnosis 1(1):43–48.

Schiff, G. D., and L. L. Leape. 2012. Commentary: How can we make diagnosis safer? Academic Medicine 87(2):135–138.

Schiff, G. D., S. Kim, R. Abrams, K. Cosby, B. Lambert, A. S. Elstein, S. Hasler, N. Krosnjar, R. Odwazny, M. F. Wisniewski, and R. A. McNutt. 2005. Diagnosing diagnosis errors: Lessons from a multi-institutional collaborative project. In K. Henriksen, J. B. Battles, E. S. Marks, and D. I. Lewin (eds.), Advances in Patient Safety: From Research to Implementation (Volume 2: Concepts and Methodology). AHRQ Publication No. 05-0021-2. Rockville, MD: Agency for Healthcare Research and Quality. www.ncbi.nlm.nih.gov/books/NBK20492/pdf/Bookshelf_NBK20492.pdf (accessed Novembe 7, 2015).

Singh, H. 2014. Editorial: Helping health care organizations to define diagnostic errors as missed opportunities in diagnosis. Joint Commission Journal on Quality and Patient Safety 40(3):99–101.

Singh, H., and D. F. Sittig. 2015. Advancing the science of measurement of diagnostic errors in healthcare: The Safer Dx framework. BMJ Quality and Safety 24(2):103–110.

Suggested Citation:"Appendix C: Previous Diagnostic Error Frameworks." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Diagnosis in Health Care. Washington, DC: The National Academies Press. doi: 10.17226/21794.
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Suggested Citation:"Appendix C: Previous Diagnostic Error Frameworks." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Diagnosis in Health Care. Washington, DC: The National Academies Press. doi: 10.17226/21794.
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Suggested Citation:"Appendix C: Previous Diagnostic Error Frameworks." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Diagnosis in Health Care. Washington, DC: The National Academies Press. doi: 10.17226/21794.
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Suggested Citation:"Appendix C: Previous Diagnostic Error Frameworks." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Diagnosis in Health Care. Washington, DC: The National Academies Press. doi: 10.17226/21794.
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Suggested Citation:"Appendix C: Previous Diagnostic Error Frameworks." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Diagnosis in Health Care. Washington, DC: The National Academies Press. doi: 10.17226/21794.
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Suggested Citation:"Appendix C: Previous Diagnostic Error Frameworks." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Diagnosis in Health Care. Washington, DC: The National Academies Press. doi: 10.17226/21794.
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Suggested Citation:"Appendix C: Previous Diagnostic Error Frameworks." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Diagnosis in Health Care. Washington, DC: The National Academies Press. doi: 10.17226/21794.
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Suggested Citation:"Appendix C: Previous Diagnostic Error Frameworks." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Diagnosis in Health Care. Washington, DC: The National Academies Press. doi: 10.17226/21794.
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Suggested Citation:"Appendix C: Previous Diagnostic Error Frameworks." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Diagnosis in Health Care. Washington, DC: The National Academies Press. doi: 10.17226/21794.
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Getting the right diagnosis is a key aspect of health care - it provides an explanation of a patient's health problem and informs subsequent health care decisions. The diagnostic process is a complex, collaborative activity that involves clinical reasoning and information gathering to determine a patient's health problem. According to Improving Diagnosis in Health Care, diagnostic errors-inaccurate or delayed diagnoses-persist throughout all settings of care and continue to harm an unacceptable number of patients. It is likely that most people will experience at least one diagnostic error in their lifetime, sometimes with devastating consequences. Diagnostic errors may cause harm to patients by preventing or delaying appropriate treatment, providing unnecessary or harmful treatment, or resulting in psychological or financial repercussions. The committee concluded that improving the diagnostic process is not only possible, but also represents a moral, professional, and public health imperative.

Improving Diagnosis in Health Care a continuation of the landmark Institute of Medicine reports To Err Is Human (2000) and Crossing the Quality Chasm (2001) finds that diagnosis-and, in particular, the occurrence of diagnostic errors—has been largely unappreciated in efforts to improve the quality and safety of health care. Without a dedicated focus on improving diagnosis, diagnostic errors will likely worsen as the delivery of health care and the diagnostic process continue to increase in complexity. Just as the diagnostic process is a collaborative activity, improving diagnosis will require collaboration and a widespread commitment to change among health care professionals, health care organizations, patients and their families, researchers, and policy makers. The recommendations of Improving Diagnosis in Health Care contribute to the growing momentum for change in this crucial area of health care quality and safety.

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