Structured case reviews for organizational learning about diagnostic vulnerabilities: initial experiences from two medical centers
-
Benji K. Mathews
,
Mary Fredrickson
Abstract
Background
An organization’s ability to identify and learn from opportunities for improvement (OFI) is key to increasing diagnostic safety. Many lack effective processes required to capitalize on these learning opportunities. We describe two parallel attempts at creating such a process and identifying generalizable lessons and learn from them.
Methods
Triggered case review programs were created independently at two organizations, Site 1 (Regions Hospital, HealthPartners, Saint Paul, MN, USA) and site 2 (University of California, San Diego). Both used a five-step process to create the review system and provide feedback: (1) identify trigger criteria; (2) establish a review panel; (3) develop a system to conduct reviews; (4) perform reviews; and (5) provide feedback.
Results
Site 1 identified 112 OFI in 184 case reviews (61%), with 66 (59%) provider OFI and 46 (41%) system OFI. Site 2 focused mainly on systems OFI identifying 105 OFI in 346 cases (30%). Opportunities at both sites were variable; common themes included test result management and communication across teams in peri-procedural care and with consultants. Of provider-initiated reviews, 67% of cases had an OFI at site 1 and 87% at site 2.
Conclusions
Lessons learned include the following: (1) peer review of cases provides opportunities to learn and calibrate diagnostic and management decisions at an organizational level; (2) sharing cases in review groups supports a culture of open discussion of OFIs; (3) reviews focused on diagnostic safety identify opportunities that may complement other organization-wide review opportunities.
Acknowledgments
The authors would like to acknowledge Thomas Yacovella, MD for his contribution to the success of the case review committee at Regions Hospital. The authors would like to acknowledge Rich Mahr, MD, for his review of this manuscript and leadership on the case review committee at Regions Hospital.
Author contributions: All the authors have accepted responsibility for the entire content of this submitted manuscript and approved submission.
Research funding: None declared.
Employment or leadership: None declared.
Honorarium: None declared.
Competing interests: The funding organization(s) played no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the report for publication.
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Articles in the same Issue
- Frontmatter
- Editorial
- Learning and teaching aren’t the same – the need for diagnosis curricula in graduate medical education
- Mini Review
- Controversies in diagnosis: contemporary debates in the diagnostic safety literature
- Opinion Paper
- Balancing confidence and humility in the diagnostic process
- Point/Counterpoints
- Roots of the total testing process
- Total testing process: roots and state-of-the-art
- Original Articles
- Embedding a longitudinal diagnostic reasoning curriculum in a residency program using a bolus/booster approach
- Structured case reviews for organizational learning about diagnostic vulnerabilities: initial experiences from two medical centers
- Breakdowns in the initial patient-provider encounter are a frequent source of diagnostic error among ischemic stroke cases included in a large medical malpractice claims database
- Perspectives from the other side of the screen: how clinicians and radiologists communicate about diagnostic errors
- Routine coagulation testing in Vacutainer® Citrate Plus tubes filled at minimum or optimal volume
- Diagnostic accuracy of fine needle aspiration cytology of thyroid nodules
- Letter to the Editor
- The day God created man
- Case Reports
- Entamoeba histolytica liver abscess case: could stool PCR avoid it?
- A rare cause of subclinical hypothyroidism: macro-thyroid-stimulating hormone
