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Closing the Loop on Diagnostic Error

By Lori Atkinson, RN, BSN, CPHRM, CPPS


Traditionally, diagnosis has been thought of as solely the physician’s responsibility; accordingly, most leaders of health care organizations take a hands-off approach. But, according to the National Academies of Sciences, Engineering and Medicine, diagnostic error is not simply failing to diagnose correctly—it’s the failure to establish an accurate and timely explanation of the patient’s health problem or communicate it to the patient.1

When we include the failure to communicate the diagnosis to the patient in a timely manner, the burden of diagnosis becomes the responsibility of the entire health care team and the systems used to support them. We call these “follow-up systems,” and they include everything from communication and workflow procedures to documentation systems. Expanding responsibility to the entire team allows us to look for gaps in timeliness and communication.

A review of Constellation malpractice claims reveals that diagnostic errors are the third most frequent type of allegation and second most costly. We found that 58 percent of all diagnostic error cases occurred in the ambulatory setting, and of these cases, 45 percent involve breakdowns in follow-up and care coordination. Our review strikingly revealed that even when appropriate clinical steps were taken to lead to a correct diagnosis, errors in diagnosis still occurred due to follow-up systems failures. Injuries and claims due to these errors are difficult to defend because they’re preventable with the implementation of reliable processes, policies and education.


What’s contributing to follow-up systems failures?

Diagnostic test and image volume is increasing. According to AHRQ, about 40 percent of patient encounters in primary care offices involve some form of medical test.2 Physician clerical burden is also increasing. The AMA estimates that physicians spend nearly two hours on EHR deskwork for every hour of clinical face time with patients,3 but many organizations don’t use a team-based care model to handle these increasing loads.

Studies also show that EHR use isn’t optimized in ambulatory care practices, with 73 percent not using EHR technologies to their full capability.4 In the hospital setting, researchers found that 70 percent of patients had at least one pending study at discharge, but only 18 percent of these were communicated in the discharge summary.5

These system inefficiencies and failures are what’s leading to diagnostic error, clinician burnout, accreditation loss, financial penalties and poor business performance.


How can we close the loop on these errors?

It takes teamwork and collaboration to make improvements to the diagnostic process. We recommend involving the entire team, including health information technology (HIT), using these three steps:


  1. Re-engineer failure-prone, inefficient processes by leveraging proven performance improvement methods, such as process mapping, Failure Modes and Effects Analysis (FMEA), PDSA cycles (Plan Do Study Act), automated audits of medical records and EHR logs, and safety scorecards.


  1. Employ policies, teamwork and tools, including implementing effective clinician-led team-based care. After re-engineering processes, develop and implement policies that outline the evidence-based practices team members are expected to follow, including test and result management, critical test result reporting, patient portal communication, and referral management. Team-based care is a strategic redistribution of work among members of a practice team in which the physician or advanced practice provider (APP) and a team of nurses and/or medical assistants (MAs) share responsibilities for patient care.4


  1. Engage, educate and support teams and patients. Care team education should outline roles and accountabilities and include how to work in a team-based care model using proven communication tools such as IPASS, SBAR and team huddles. Patient engagement education should incorporate health literacy tools such as Ask Me 3, teach-back and empathetic communication.


Improving diagnosis by addressing follow-up systems reduces risk, improves team productivity, and affects an organization’s reputation and bottom line by improving patient experience and incurring fewer malpractice claims. It’s a win-win for all.


Lori Atkinson, RN, BSN, CPHRM, CPPS, is a patient safety expert at Constellation, a growing portfolio of MPL insurance and “beyond insurance” companies dedicated to reducing risk and supporting physicians and care teams, thereby improving business results. To learn more about the services UMIA provides to physicians, hospitals and health systems, visit



  1. National Academies of Sciences, Engineering, and Medicine. 2015. Improving diagnosis in health care.
  2. AHRQ: Improving Your Laboratory Testing Process.
  3. AMA: STEPS Forward.
  4. Rumball-Smith J, Shekelle P, Damberg CL. Electronic health record “super-users” and “under-users” in ambulatory care practices. J Manag Care. 2018;24(1):26-31.
  5. Kantor MA, Evans KH, Shieh LJ. Pending studies at hospital discharge: a pre-post analysis of an electronic medical record tool to improve communication at hospital discharge. J Gen Intern Med. 2015;30(3):312-8.

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