Diagnostic error is a difficult issue to track in the emergency department (ED). For a good reason, too: The patient population is so transient it’s difficult to detect a “missed” diagnosis. It’s less readily apparent than medication errors, falls, and other commonly reported incidents.

But that’s precisely what makes diagnostic error such an insidious problem.

Recent research into malpractice claims over a five-year period suggests that 28 percent of all diagnostic error occurs in the ED, with 67 percent of incidents involving elements of clinical decision-making. Moreover, the consequences are significant: Data indicates that 52 percent of diagnostic errors in the ED result in death (36 percent) or a high-severity injury (16 percent).

There’s no escaping the fact that EDs are high-pressure, whirlwind environments uniquely fraught with the risk of diagnostic error. Providers must draw conclusions quickly, with limited (or non-existent) patient histories. Patient acuity is typically high. Priorities must constantly shift.

Although a degree of chaos is unavoidable, it makes decision-making difficult—and clinical decision-making is the foundation of the diagnostic process. Therefore, we must create an environment of controlled chaos—i.e., enabling fast-paced but orderly team-based processes for gathering, synthesizing, and communicating all the information necessary to arrive at an accurate diagnosis.

Build a culture to support diagnostic accuracy.

Relying on intuitive thinking and experience is an essential part of the “art” of medicine. It’s what leads us to say, “I’ve seen this presentation a million times; I know what it is.”

However, ED providers accustomed to making quick diagnosis and treatment decisions under intense pressure sometimes develop an over-reliance on intuitive thinking. In ED settings, it can cause providers to jump from points A to B without thoroughly examining what lies in between—thus inadvertently introducing biases or shortcuts that can set the stage for diagnostic error.

Therefore, giving providers the tools to move away from relying solely on intuitive thinking is crucial. Organizations should nurture a culture that acknowledges—and normalizes—diagnostic uncertainty.

That includes eliminating the idea that diagnosis is an ED physician’s individual responsibility. While the treating/attending physician is ultimately responsible for the diagnosis, in truth, the entire care team contributes. Diagnostic accuracy should be considered as much a “team sport” as all other aspects of health care. That means encouraging physicians’ introspection and creating a safe environment for others to speak up with questions or opposing views.

How?

Tip 1: Embolden ED providers to admit and communicate when diagnostic uncertainty exists. For example, they could use the term “working diagnosis” when documenting or discussing their diagnostic thought process. Such transparency typically delivers more benefits than risks because it bolsters:

• Patient/family engagement. A patient’s condition can change rapidly during their ED stay. Discussing the “working diagnosis” is a strategy to engage the patient and their family to become part of their own care team.
• Subsequent care. Transparency in the medical record—including the fact that a diagnosis is only a working diagnosis—helps other providers better understand the original provider’s thought processes and conclusions.
• Diagnostic accuracy through time-outs. Communicating diagnostic uncertainty can be used to trigger a diagnostic time-out process, which allows ED providers to assemble a small team to gut-check their thinking and guard against any intuitive thinking or potential biases that may have skewed their reasoning. Similar to a surgical time-out, a diagnostic time-out enables a moment of reflective thought in a team setting.

The key is to foster a collaborative, high-performance culture in which providers feel comfortable with diagnostic uncertainty, curiosity, and others’ ability to question diagnostic determinations.

9 additional tips to build a culture of diagnostic accuracy

1. Educate everyone on the ED team about the many kinds of cognitive biases, how they relate to diagnostic error, and how to minimize them.
2. Empower ED teams to examine their own thinking patterns and challenge others if they believe inadvertent cognitive bias may be at play. Ensure staff are comfortable escalating any concerns through a good chain-of-command policy.
3. Encourage ED physicians to acknowledge that diagnosis is a team sport and that accuracy improves when they actively engage others to resolve uncertainties.
4. Foster respectful communication among ED team members that promotes questioning (e.g., “I’m curious about your thoughts…” instead of “That can’t be right!”).
5. Create strategies to minimize interruptions for ED physicians—such as implementing huddles to streamline communication. Studies show that minimizing interruptions reduces medication errors; perhaps it could likewise mitigate diagnostic error.
6. Ensure electronic health record (EHR) and other technology systems support the diagnostic process. Shadow providers as they use the systems, then work with technology vendors to address any issues and ensure pertinent patient information needed to arrive at a diagnosis is easy to find for the user.
7. Recognize diagnostic error as an “event” worthy of being reported in an event system—just like medication errors, pressure ulcers, or patient falls—and used as part of learning in a high-performing organization.
8. Track, trend, and dig into metrics that may subtly indicate diagnostic error, such as when ED patients request medication refills, when they call back with unresolved symptoms, or when final imaging or test results differ from the original.
9. Develop strong handoff processes to ensure vital clinical information isn’t dropped when providers’ shifts end.

Collaborate, question, and reduce errors

ED providers seldom have the benefit of rich patient clinical histories, so ED teams must be alert to subtle indicators that a diagnosis might not be correct, such as:

• Test results that don’t seem to fit the case.
• Symptoms that don’t improve.
• Patient transfers to a higher level of care.

Reducing diagnostic error requires ED providers to reassess their conclusions periodically. It requires organizations to cultivate a culture where it’s OK to question, “Have we anchored on a common diagnosis (anchoring bias)? Have we focused too narrowly on test results that support our hypothesis (confirmatory bias)? Is the patient’s treatment response going in the expected direction?”

With a better understanding of contributing risk factors and mitigation strategies, organizations can reduce the prevalence of diagnostic error in the ED.

Susan L. Montminy and Marlene Icenhower are health care executives.