Northwestern Memorial Healthcare

The Effect of Diagnostic Error Feedback to Emergency Department Physicians and Residents

Project Lead: Gopi Astik, M.D., M.S.

Project AIM(s):

  1. We plan to calculate a baseline rate of diagnostic errors in Northwestern Memorial Hospitals Admissions from the Emergency Department (ED) to Hospital Medicine service within 6 months. The rate will be calculated by administering twice weekly surveys about diagnostic changes in transition from ED to hospital medicine.
  2. Once the error rate is calculated, the team will evaluate the types of errors and look for trends to incorporate into educational processes to improve diagnoses. ED providers involved will receive feedback. At the end of one year, it will be determined if the types or rates of errors occurring changed with implementation of feedback.

Narrative Description

The focus area of this project was the effects of diagnostic error feedback on ED Physicians and Residents amongst patients that visited Northwestern Medical Center for various medical issues. By calculating the baseline rate of diagnostic errors within the ED, the team evaluated the types of errors and looked for trends to incorporate into educational processes to improve diagnoses. The survey process began in March 2021 with 292 surveys sent and an impressive 84% response rate. The survey period was extended for another six months to complete one year of surveys to have a more robust data set.  

Phase two focused on providing feedback to the Emergency Department based on the focused case reviews/ We provided cases deemed to have diagnostic errors to the ED education team to use for educational sessions and review with their team. The cases and review process were discussed with the ED education team to answer any questions and discuss takeaways. The trends in errors were provided to the ED leadership, and we also helped plan educational sessions for the ED learners. The top trends that were identified and selected as focal points were Incomplete histories, Heart failure, and Dermatology follow-up cases.

Incomplete histories: The source either lacked patient information/questioning or lacked comprehensive chart review, which led to the error. For example, the patient was admitted with chest pain deemed to be cardiac in nature despite normal labs, and a comprehensive EMR review would have shown a negative recent coronary angiogram making an acute coronary event very unlikely.  

Heart failure: The diagnosis of heart failure was also a trend noticed in our hospital medicine work. We found both over- and under-diagnosis of heart failure exacerbations in patients. For example, the patient received diuretics in the setting of sepsis and lack of biomarker elevation or, conversely, patients treated for pneumonia when chest imaging showed fluid and not an infection.  

Dermatology cases: There was a trend of dermatology cases where the diagnosis was delayed and not considered or mentioned in the ED workup.

In summary, we found a focal point of the diagnostic error rate of ~7% on admission from the ED to the hospital medicine service. We also provide trends in diagnostic errors to ED leadership. We discussed cases with errors with the ED team during educational sessions and obtained feedback from the ED team on the value of this feedback. Time and other constraints related to the pandemic limited the ability to provide more robust individual feedback to ED clinicians, but we still feel that what was provided is helpful. We plan to continue reviewing the subsequent six months of cases to calculate a diagnostic error rate over one year and provide more education to the ED team.

Diagnostic quality problem type, failure, or category (symptoms, observed problems, gaps in performance) addressed by the intervention

  • Failure to access the health care system or engage in the diagnostic process
  • Failure in information interpretation
  • Failure to establish an explanation (diagnosis)

Root causes/causative factors addressed by the intervention

  • Patient-clinician interaction (includes patient and family engagement)
  • Workflow (includes testing, follow-up, and referrals)
  • Diagnostic patient safety culture
  • Identifying/investigation/sharing diagnostic errors

Setting of the diagnostic quality improvement intervention

  • Emergency department
  • Acute care hospital inpatient area