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How to Let Clinicians Know They Missed a Diagnosis


By Divvy K. Upadhyay, MD, MPH; Ashley N.D. Meyer, PhD; and Hardeep Singh, MD, MPH

In the February 2021 issue of The Joint Commission Journal on Quality and Patient Safety, we describe findings from a pilot program to provide frontline clinicians feedback on their cases that involved missed opportunities to make correct and timely diagnoses. All of these cases, categorized as diagnostic errors or delays, were considered as learning opportunities. 

It is not common for frontline clinicians to receive feedback on their diagnostic performance. Not only are there no formal systems to do this but clinicians may be uncomfortable with such feedback. This is not surprising because diagnosis is the heart of medicine and clinicians pride themselves on having good diagnostic skills. However, diagnostic errors are not uncommon and feedback improves performance. In fact, the landmark 2015 report from the National Academies of Medicine, Improving Diagnosis in Health Care, highlights that “health care organizations should promote a non-punitive culture that values feedback on diagnostic performance.” 

The intent of the feedback program, developed collaboratively by a partnership between Geisinger’s Committee to Improve Clinical Diagnosis (CICD) and researchers from Baylor College of Medicine, was to make every diagnostic error an opportunity for learning. This partnership, also known as the Safer Dx Learning Lab (the Lab), was established in 2017 in an effort to enhance diagnostic safety activities and foster collaboration between clinical operations leaders and diagnostic safety research experts. The CICD gathered support from organizational leaders who were already looking for strategies to deliver constructive and non-punitive feedback that could be useful to clinician learning. 

Highlights of Program Development 
Of high importance was to plan feedback mechanisms carefully using evidence-based literature and to study the process and its acceptability. One question we faced was “Who would be the best individual to provide feedback?” Would it be a peer, a respected individual or the individual regarded as the master diagnostician?  

The CICD chose to partner with department and quality directors, because these leaders enthusiastically stepped up. They felt this was part of their job, and in some ways, their natural responsibility as leaders to provide guidance, feedback and support to their staff. They recognized that clinicians may be apprehensive receiving feedback about key tasks related to their professional responsibility and were sensitive to that concept.  

But prior research suggests a supervisor might not be the best person to provide feedback. Not everyone truly relishes receiving a call or email from the director to discuss “a case” or “something that’s come up about a patient,” even if it comes from a friendly and supportive boss. Also, local culture varies from department to department not just between organizations or regions. The camaraderie and bonding between staff members and their rapport with leadership varies. Fortunately, this initiative was met with general receptivity and across-the-board support. 

Generally speaking, for such an initiative, the biggest challenge is finding time and support from clinicians and leaders (who are typically working at capacity and spread thin). We aligned our efforts with the CICD’s intention to:

  • provide an environment in support of a culture of safety and learning
  • encourage open and transparent discussions on improving diagnosis

Difficult conversations about improvement likely already happen between leaders and their clinical staff but our findings show it may be beneficial to have structured debriefs where missed diagnostic opportunities are reviewed and lessons are identified together in a constructive manner. 

We also developed a partnership with Geisinger’s Center for Professionalism and Well-Being to assist department leaders with helpful strategies to keep clinicians’ well-being at the center while dealing with sensitive issues. The work led to a feedback toolkit and visual guide informed by evidence-based research.

Any Takers? 
Health system leaders and quality and safety professionals reading this should consider addressing the challenge of diagnostic errors and providing feedback to clinicians. Our paper offers a pragmatic start and we have had interest from a few interested folks already. 

The National Academies of Medicine report highlights that “few health care organizations have processes in place to identify diagnostic errors and near misses in clinical practice…but collecting this information, learning from these experiences, and implementing changes are critical for achieving progress.”  

In the long run, accrediting bodies, payors or regulatory agencies, may even require health care organizations to have a meaningful diagnostic safety surveillance and improvement program (or other mechanisms) in place to identify and learn from diagnostic errors in a systematic manner. But we do not need to wait on that to happen. We hope that our program inspires a few other early adopters to take on this challenge.

Divvy K. Upadhyay, MD, MPH, is a Scientist in the Division of Quality, Safety and Patient Experience and the ‘Safer Dx Researcher-in-Residence’ at Geisinger, Danville, Pennsylvania. Ashley N.D. Meyer, PhD, is a Cognitive Psychologist in the Health Policy, Quality and Informatics Program at the Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey VA Medical Center (MEDVAMC), Houston, and Assistant Professor at BCM. Hardeep Singh, MD, MPH, is Chief of the Health Policy, Quality and Informatics Program at IQuESt, MEDVAMC, and Professor of Medicine at BCM.