Safety in Numbers: Improving Diagnosis Through Teamwork

In recent years, numerous groups and individuals — including advocacy groups, researchers, healthcare providers, and others — have raised awareness and increased understanding about diagnostic errors, drawing attention to the profound effect that these errors have on patients, families, and clinicians.

Although exact numbers are not known, studies suggest that the diagnostic error rate is in the range of 5-15 percent, with variations across specialties.¹ Dr. Hardeep Singh, a renowned expert on diagnostic errors and a reviewer for the Institute of Medicine’s (IOM’s) influential report Improving Diagnosis in Health Care, has estimated that 1 in 20 U.S. adults will experience a misdiagnosis every year — a staggering statistic.² Further, diagnostic errors likely contribute to 40,000-80,000 patient deaths in the United States annually.³

The efforts to shed light on delayed, wrong, and missed diagnoses have drawn clear attention to the scope and impact of these medical errors. What isn’t as clear is how to address these issues and develop effective and viable solutions. A number of potential strategies have been proposed, including implementing techniques to improve teamwork, integrating evolving technologies (such as clinical decision support systems), adjusting processes and workflows, using diagnostic pathways, and exploring debiasing techniques.

Of these various strategies, the IOM places significant emphasis on facilitating better teamwork to strengthen the diagnostic process in Improving Diagnosis in Health Care. This recommendation includes supporting an environment that is conducive to collaboration, providing technology that assists with communication, establishing measurable processes and feedback mechanisms, and engaging patients and their families in the diagnostic process.

The IOM’s recommendation related to improved teamwork represents a major conceptual shift because it distributes diagnostic responsibility across the “diagnostic team” rather than placing responsibility solely on the treating clinician — a model that has been the standard for hundreds of years.⁴ To this end, the IOM notes that the diagnostic team must have the knowledge, skills, resources, and competency to support the diagnostic process, which healthcare organizations should facilitate through interprofessional and intraprofessional teamwork and collaboration.⁵

Although the concept of the diagnostic team is seemingly straightforward, its execution in various care settings is much more complex. A 2017 opinion paper in Diagnosis, authored by a number of healthcare experts, sought to provide guidance on how individuals and organizations can bring the concept of the diagnostic team to fruition. At a high level, these recommendations include:

• Incorporating education and training related to team paradigms and effective collaboration into undergraduate and postgraduate medical and health-related curricula.

• Adapting to an evolving workforce in which nonphysician providers — such as nurse practitioners and physician assistants — are increasingly involved in and leading the diagnostic process. Providers and staff within organizations should understand the scope of each clinician’s practice and be aware of various team members’ roles and responsibilities.

• Integrating allied healthcare professionals — such as pharmacists, medical technologists, physical and occupational therapists, etc. — into the diagnostic team in appropriate circumstances.

• Creating a culture of collaboration that encourages members of the diagnostic team to participate and provide feedback. For example, team members should feel comfortable asking questions, making suggestions, and offering alternative hypotheses.

• Determining best practices and expectations for various types of communication, such as documentation in electronic health records, handoff procedures, and referrals/consultations. Including team members in the process of establishing these protocols can help facilitate awareness and support.

• Using collaborative care rounds or staff huddles to facilitate communication among clinical disciplines and to review patient assessments, working diagnoses, differential diagnoses, and care plans.

• Seeking internal and external feedback on performance, including constructive criticism from members of the diagnostic team, others within the healthcare organization, patients, and other providers who are involved in patients’ care.

• Communicating verbally, rather than electronically, with clinicians and professionals in diagnostic support services, such as laboratory and radiology professionals.

• Consulting directly with pathologists about test selection and results interpretation, and seeking/providing feedback regarding testing and errors.

• Including patients/families as part of the diagnostic team through various engagement strategies, such as:
  
  • Inviting patients/families to be active participants in the diagnostic process. For example, clearly explain the process and encourage patients to provide thorough information about their health and medical histories, ask questions (e.g., “What else could cause these symptoms?”), and follow up on test and laboratory results.
    
  • Optimizing verbal and electronic communication with patients to ensure they have access to necessary systems (e.g., patient portals) and that information is timely and accurate (e.g., voicemail and email responses).
    
  • Communicating information to patients in ways that they can understand, such as using visual aids, providing plain-language educational materials, and using techniques such as “teach-back” to assess comprehension.
    
  • Providing patient-friendly tools to assist with information management, encourage dialogue, and support collaborative problem-solving. Examples of useful tools include Be Prepared to Be Engaged (Agency for Healthcare Research and Quality), Ask Me 3 educational program (Institute for Healthcare Improvement), and The Patient’s Toolkit for Diagnosis (Society to Improve Diagnosis in Medicine).
    
  • Working with patients/families to develop shared knowledge and goals as well as to foster mutual respect.
    
  • Encouraging patients to transfer relevant health records to treating clinicians and to review any health information available via patient portals for accuracy and completeness.

Using a team approach to improve quality and safety in healthcare is not a new concept; however, using this model to guide the diagnostic process diverges from the centuries-old norm of the treating provider as the solo diagnostician. Although research on the effectiveness of teamwork in diagnostic evaluation and decision-making is limited, the approach shows promise when properly executed. For more information, read the full details of the Diagnosis opinion paper and see the IOM’s report Improving Diagnosis in Health Care.

Endnotes

¹ The Society to Improve Diagnosis in Medicine. (n.d.). Facts: Improving diagnostic accuracy in medicine. Retrieved from www.improvediagnosis.org/page/Facts; Crosskerry, P. (2013, June). From mindless to mindful practice — cognitive bias and clinical decision making. New England Journal of Medicine, 368(26), 2445-2448.

² Landro, L. (2015, September 26). A medical detective story: Why doctors make diagnostic errors. The Wall Street Journal. Retrieved from www.wsj.com/articles/a-medical-detective-story-why-doctors-make-diagnostic-errors-1443295859

³ The Society to Improve Diagnosis in Medicine. (n.d.). Diagnostic error: Common, costly, and harmful. Retrieved from www.improvediagnosis.org/page/Diagnosis

⁴ Graber, M., Rusz, D., Jones, M., et al. (2017). The new diagnostic team. Diagnosis, 4(4), 225-238.

⁵ National Academies of Sciences, Engineering, and Medicine. (2015). Improving diagnosis in health care. Washington, DC: The National Academies Press.

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