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Patient safety supplement

Diagnosis - Get it right, make it safe WPSD 2024

Published on: 17/09/2024

The theme of the World Health Organization (WHO) World Patient Safety Day 2024 is “Improving diagnosis for patient safety” supported by the slogan “Get it right, make it safe!” This Patient Safety Supplement is a first instalment in a short series on improving diagnosis for patient safety.

Diagnosis is an essential part of healthcare, it is very often the first step into the healthcare system. Diagnosis can be defined as “the process of identifying a disease, condition, or injury from its signs and symptoms.

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“Get it right, make it safe!”

The theme of the World Health Organization (WHO) World Patient Safety Day 2024 is “Improving diagnosis for patient safety” supported by the slogan “Get it right, make it safe!” This Patient Safety Supplement is a first instalment in a short series on improving diagnosis for patient safety.

Diagnosis is an essential part of healthcare, it is very often the first step into the healthcare system. Diagnosis can be defined as “the process of identifying a disease, condition, or injury from its signs and symptoms. A health history, physical exam, and tests, such as blood tests, imaging tests, and biopsies, may be used to help make a diagnosis”. In developed countries, diagnosis is responsible for about 10% of healthcare expenditure - a proportion that is increasing faster than other areas such as treatment or care, for several reasons including the advancement of diagnostic capability (radiology, endoscopy, genetic testing) and the desire to limit uncertainty.

Diagnostic Incident Reporting Diagnostic Incident Reporting

Diagnosis can be simple but it can be very complex and because it is so pivotal in terms of determining prognosis, prevention and treatment it is also potentially dangerous. The WHO and the National Academy of Medicine (NAM) (US) have identified measuring and reducing diagnostic error as a patient safety priority.

Expert Model of Diagnostic Process

Given that diagnosis has multiple steps over time it is useful to view it as a process. This Diagnostic Process was described in a 2015 landmark report on Improving Diagnosis in Health Care from the US National Academies of Medicine.

The purpose of this diagnostic process is firstly; to achieve a timely and accurate diagnosis and secondly; to communicate that diagnosis in a person centred way.

The model describes the key steps of diagnosis so that we can understand how it happens, how things might go wrong and how we might improve.

Understandably this model starts with the patient; recognising a problem and engaging with the health system for help. Issues here might include the ability to access clinicians in a timely fashion and the public’s understanding of signs and symptoms of disease.

The next section of this model is the core of the diagnostic process where a clinician gathers information, integrating and interpreting it to come up with working diagnosis. This involves a patient history, physical exam and investigations that might include blood tests, imaging or special tests such as a scope, a biopsy or an angiogram depending on the situation.

This part of the diagnostic process is often iterative, updating working diagnoses depending on the results of investigations until at some point, though not always, a conclusion is reached. All of this happens within a “work system” that includes people (e.g. clinicians, administrators), places such as the hospitals or GP surgery and technology such as IT for processing and sharing information or special equipment for imaging (e.g. X-ray, ultrasound).

Traditionally diagnosis was the remit of the doctor, and may still be seen as a defining feature of what it is to be a doctor, but increasingly the patient themselves and other healthcare professionals are making diagnoses including nurses and many health and social care professionals including pharmacists, dieticians, psychologists, occupational therapists and physiotherapists.

The role of the Patient in diagnosis

Patients are playing an increasingly important role in diagnosis, with improved medical literacy and easy access to medical information, many patients are willing, able and expect to play an active role as partners in diagnosis.

The HSE’s “My Health, My Voice” is a patient leaflet to aid diagnostic safety. It supports patients to be active in their care and diagnosis.

Margaret Murphy is one of the first patient partners in Ireland and has spent her life advocating for patients, their families and healthcare staff. Margaret is the External Lead Advisor for the WHO’s World Alliance for patient safety, a network of 400 patient safety champions from 52 countries and is the founding member of Patients for Patient Safety Ireland.

In the QPS Walk and Talk Improvement Podcast Series (Season 1, Ep. 14) Margaret shares how she has coped with the loss of her son Kevin due to a medical error involving diagnostics and how she used this experience for change across healthcare.

Margaret Murphy - life with Kevin and the beginnings of patient partnership (https://shows.acast.com/walk-and-talk-improvement/episodes/margaret-murphy-life-with-kevin-and-the-beginnings-of-patien

Using diagnostic tests, clinical judgement and referring patients to suitably qualified and experiences experts are key elements of diagnostic care and improving diagnostic accuracy. There are also many supports available to help clinical staff and patients collaborate to reach a correct diagnosis, including Ward Rounds, Multidisciplinary Team Meetings, Safety Pauses and Safety Huddles. For World Patient Safety Day 2024 Poster resources on improving diagnosis are available from the WHO and can be downloaded and shared (https://www.who.int/multi-media)

Expert Comment

by

Dr John Fitzsimons

Consultant Paediatrician / Clinical Director Quality Improvement / Lead Faculty for Quality Improvement & Patient Safety Education - RCPI

Considering the complexity of diagnosis it is not surprising that things can go wrong. Using the model we can identify parts of the process where incidents can occur. Some incidents are to be found in the work system for example in accessing diagnostics or how results are followed up or communicated. Knowing how and where these problems might occur and having good work processes such as clear accountability for following up results or the provision of safety nets works here.

An area noted to be particularly susceptible to an incident occurring is that of integrating and interpreting information in the core diagnostic process (red circle in Figure 1 above). Here, a clinician’s cognitive bias, such as confirmation bias (only paying attention to information that confirms your hypothesis, while ignoring other potentially important information) or premature closure (stopping at a working diagnosis too early before the correct diagnosis is discovered) can lead to delayed or inaccurate diagnosis.

Clinicians need to be aware of how biases (mental short cuts that usually help us) can lead us astray. Clinicians also need to be able to balance their ability to make an accurate diagnosis with a sense of how confident they are in their decisions (diagnostic calibration) and knowing when they should ask for further information or diagnostic help. Making diagnosis a team pursuit (including the involvement of patients and families) can help avoid these traps.

Another area of potential error is in that of investigation. No test is perfect and many tests are dependent on human performance. There are many potential solutions here including good diagnostic calibration, audit and feedback, transparency and a strong learning safety culture. New technologies, including AI (artificial intelligence), are starting to help enhance the diagnostic specialties in fields such as radiology.

An inherent feature of diagnosis is uncertainty but the solution to better diagnosis is not necessarily more investigation. The problem of overdiagnosis is also recognised where people become patients unnecessarily, by identifying problems that were never going to cause harm or by medicalising ordinary life experiences through expanded definitions of diseases. This can then lead to unnecessary treatment and anxiety.

Recently the concept of Diagnostic Excellence (DxEx) has been proposed as a way to blend all these competing demands (Meyer & Singh, JAMA 2019). Diagnostic Excellence involves making a correct and timely diagnosis using the fewest resources while maximising patient experience and managing uncertainty. This idea acknowledges that most diagnosis is done well but that there are certain interventions that can improve it and make it safer. New resources have been produced to promote and support DxEx at the level of individual clinicians, professional bodies and at the health system level.

So let’s all support World Patient Safety Day 2024 and play our part in getting diagnosis right and making it safe.

Please visit for more information and to access resources on World Patient Safety Day:

References

This Patient Safety Supplement was developed by:

Dr John Fitzsimons

Consultant Paediatrician / Clinical Director Quality Improvement /

Member of the HSE National Patient Safety Alert Committee /

Lead Faculty for Quality Improvement & Patient Safety Education - RCPI

With support from:

Patient Safety Together

  • Incident Management Team, National Quality and Patient Safety Directorate, HSE

QPS Connect

  • National Quality and Patient Safety Directorate, HSE

Approved for publication by the HSE National Patient Safety Alert Committee and the National Clinical Director, NQPSD

For further information on Patient Safety Supplements, see www.hse.ie/pst

All feedback on content or format of this supplement is welcome and can be sent to patientsafetytogether@hse.ie