Diagnosis: Reducing Errors and Improving Quality¶
Chapter 10 | Part 1: The Profession of Medicine
KEY CLINICAL POINTS¶
- Diagnostic errors are the leading type of medical error, with 40,000-80,000 patients dying annually in U.S. hospitals from diagnostic errors
- Diagnosis is a systems property requiring coordinated teamwork among clinicians, patients, and families—not solely dependent on individual physician expertise
- Cognitive biases (premature closure, anchoring, confirmation bias) are major contributors to diagnostic errors but are interwoven with system failures
- The NAM defines diagnostic error as 'the failure to establish an accurate and timely explanation of the patient's health problem(s) or communicate that explanation to the patient'
- Health information technology, safety culture transformation, and reliable follow-up systems are essential for diagnostic improvement
1. DEFINITION & OVERVIEW¶
Diagnosing patients' illnesses is the essence of medicine. Patients present seeking an answer to 'What is wrong with me?' The National Academy of Medicine (NAM) defines diagnostic error as 'the failure to (a) establish an accurate and timely explanation of the patient's health problem(s) or (b) communicate that explanation to the patient.' Basic internal medicine diseases such as asthma, pulmonary embolism, congestive heart failure, seizures, strokes, ruptured aneurysms, depression, and cancer are misdiagnosed at shockingly high rates, often with 20-50% of patients either being mislabeled (false-positive diagnoses) or having their diagnosis missed or delayed (false negatives). The Venn diagram concept illustrates that many things can go wrong in the diagnostic process (failure to ask important history questions, physical exam signs overlooked, laboratory specimens switched, x-rays not followed up), but this usually does not result in wrong diagnosis or patient harm. Similarly, patients can be misdiagnosed but unharmed without identifiable error. The greatest concern is where these three circles intersect—conservative estimates suggest 40,000-80,000 patients die annually in U.S. hospitals alone from diagnostic errors.
National Academy of Medicine Recommendations for Improving Diagnosis in Health Care¶
| Recommendation Number | Description |
|---|---|
| 1 | Facilitate more effective teamwork in the diagnostic process among health care professionals, patients, and their families |
| Recommendation Number | Description |
|---|---|
| 2 | Enhance professional education and training in the diagnostic process in areas such as clinical reasoning; teamwork; communication with patients, families, and other health care professionals; and appropriate use of diagnostic tests |
| 3 | Ensure that health information technologies support patients and health care professionals in the diagnostic process |
| 4 | Develop and deploy approaches to identify, learn from, and reduce diagnostic errors and near misses in clinical practice including providing systematic feedback on diagnostic performance |
| 5 | Establish a work system and culture that supports the diagnostic process and improvements in diagnostic performance |
| 6 | Develop a reporting environment and medical liability system that facilitates improved diagnosis by learning from diagnostic errors and near misses |
| 7 | Design a payment and care delivery environment that supports the diagnostic process |
| 8 | Provide dedicated funding for research on the diagnostic process and diagnostic errors |
1.1 Diagnosis as a System Property¶
Good diagnosis does not rest entirely on individual clinicians' shoulders. Instead, it is a systems property where infrastructure and team (especially including the patient) work together in a coordinated way to achieve more reliable and optimal diagnosis. The sciences contributing to diagnostic safety include: - Systems and human factors engineering - Reliability science - Cognitive psychology - Decision sciences - Forensic science - Clinical epidemiology - Health services research - Decision analysis - Network medicine - Learning health systems theory - Medical sociology - Team dynamics and communication - Risk assessment and communication - Information and knowledge management - Health information technology (AI and clinical decision support)
1.2 Emergence as a Patient Safety Issue¶
Over the past two decades, studies culminating in the NAM landmark report 'Improving Diagnosis in Health Care' have spotlighted diagnostic errors. Reports from patient surveys, malpractice claims, and safety organizations consistently find diagnostic errors as the leading type of medical error.
2. ETIOLOGY & PATHOPHYSIOLOGY OF DIAGNOSTIC ERRORS¶
Diagnostic errors arise from a complex interplay of cognitive biases, system failures, and process breakdowns. Errors in clinical reasoning can be summarized into three broad groups: 1. Hasty judgments 2. Biased judgments 3. Inaccurate probability estimates Research from cognitive psychology has identified scores of common mental shortcuts or 'heuristics' humans use in everyday life. Many are useful for efficient diagnosis but can lead to biases and errors.
Selected Cognitive Biases Contributing to Diagnostic Errors¶
| Bias | Description |
|---|---|
| 1. Premature closure | Accepting a diagnosis before it has been fully verified |
| 2. Anchoring | Tendency to fixate on a specific symptom or piece of information early in the diagnostic process with subsequent failure to appropriately adjust |
| 3. Confirmation bias | Tendency to look for confirming evidence to support one's diagnostic hypothesis, rather than disconfirming evidence to refute it |
| 4. Search satisficing | Tendency to call off a search, satisfied once a piece of data or presumed explanation is found, and not considering/searching for additional findings or diagnoses |
| 5. Availability bias | Tendency to give too much weight to diagnoses that come more readily to mind (e.g., recent dramatic case) |
| 6. Base-rate neglect | Failing to adequately take into account prevalence of a particular disease (e.g., erroneously interpreting a positive test as indicating disease in a low-prevalence population using a test with 5% false-positive rate) |
| 7. Knowledge deficit | On part of provider, with accompanying lack of awareness |
| 8. Framing bias | Judgment overly influenced by the way the problem was presented (how it was framed in words, settings, or situations) |
| 9. Social/demographic/stereotype bias | Biases from personal or cultural beliefs about women, historically marginalized populations such as African Americans, people with differing sexual identities, or other patient groups for whom prejudices may distort diagnostic assessment |
2.1 System Factors¶
Beyond cognitive biases, diagnosis is challenged by: - Limitations of human memory - Information shortfalls - Constrained encounter time - System process failures - Myriad nonspecific symptoms patients bring - Many symptoms are self-limited, defy precise diagnosis, and do not portend harmful outcomes
2.2 Multifactorial Nature¶
Errors are multifactorial with interwoven, interacting, and inseparable cognitive and system factors. Classification as either purely 'system' or 'cognitive' errors is overly simplistic.
3. NEW PARADIGMS FOR DIAGNOSIS IMPROVEMENT¶
Traditional paradigms of diagnosis are being challenged by new insights from safety science and cognitive research. Classic teaching exhorting trainees to have a broad differential and 'high index of suspicion' is challenged by unconscious biases, human memory limitations, constrained encounter time, and myriad nonspecific symptoms.
New Models for Conceptualizing Diagnosis and Diagnosis Improvement¶
| Traditional Thinking | New Paradigm/Better Approach |
|---|---|
| A good diagnostician gets it right the first time, almost all of the time | Diagnosis is an inexact science with inherent uncertainties; Goal is to minimize errors and delays via more reliable systems and follow-up |
| Lore of masterful/skillful academic expert diagnostician who knows/recalls everything | Less reliance on (fallible) human memory; Quality diagnosis is based on well-coordinated distributed network/team of people and reliable processes; All patients entitled to quality diagnosis regardless of where/from whom they receive care |
| Diagnosis is the doctor's job | Co-production of diagnosis among clinicians (including lab, radiology, specialists, nurses, social workers) and especially the patient and family |
| Patients often viewed as overly anxious, exaggerating, time-consuming, with unreasonable demands | Patients are key allies in diagnosis; hold key information; Need to address understandable/legitimate fears, desires for explanations; Leverage patient questions to stimulate rethinking diagnosis where needed |
| Order lots of tests to avoid missing diagnoses | Judicious ordering: targeted, well-organized data and testing; Appreciation of test limitations (false positives/negatives, incidental findings, overdiagnosis, test risks) and resulting harms |
| More referrals to avoid missing rarer/specialized diagnoses | 'Pull systems' to lower barriers and make it easier to pose questions, obtain real-time virtual consults; Co-management approaches for collaborative watch-and-wait conservative strategies |
| Frequent empirical drug trials when uncertain of diagnosis | Conservative use of drugs to avoid confusing clinical picture or labeling patients with diseases they may not have |
| Diagnostic error viewed as a personal failing | Many errors/delays rooted in processes and system design/failures |
| Errors classified as either 'system' or 'cognitive' | Errors multifactorial with interwoven, interacting, and inseparable cognitive and system factors |
| Errors are infrequent; hit-and-miss ways to learn about errors | Errors are common; systematic proactive follow-up needed to recognize potential for errors; Surveilling high-risk situations and one's own diagnostic performance and outcomes |
| Clinicians' reactions: denial, defensive, blaming others | Culture of actively and nondefensively seeking to uncover, dig deep to learn from, and share errors and lessons |
| Traditional Thinking | New Paradigm/Better Approach |
|---|---|
| Documentation as time-consuming, mindless, primarily for billing or malpractice defense | Documentation as useful tool for reflecting, crafting, sharing assessments, differential diagnosis; Opportunities for decision support interacting with computer; Notes open for patients to read |
| Say/write as little as possible about uncertainties | Share uncertainties to maximize communication and engagement with other caregivers, patients |
| Don't let patient know about errors so they don't sue | Patients have right to honest disclosure; often find out about errors anyway; anticipate, engage their concerns |
| 'We'll call if anything is abnormal' | Systematic proactive follow-up to close loop on all tests and worrisome symptoms, check how patient is doing, monitor outcomes |
| Knowing/memorizing more medical knowledge | Knowing more about the patient (psychosocial, past history, environmental contexts) |
| Attention to 'objective' data (physical exam, tests) | Renewed emphasis on history, history-taking, listening; Acknowledgment of ubiquitous subjective cognitive biases; efforts to anticipate, recognize, counteract |
| Exhortations to have 'high index of suspicion' | Less reliance on memory recall; more just-in-time info look-up; Affordances, alerts to red flags engineered into workflow; Delineation of 'don't miss' diagnoses with context-relevant decision support |
| CME courses to expand medical knowledge | Real-time, context-aware reminders of pitfalls, critical differential diagnoses, and key differentiating features; Ready access to medical references, second opinions |
| Fear of malpractice suits to motivate careful practice | Drive out fear, make it safe to learn from and share errors; Shared situational awareness of where pitfalls lurk |
| More accountability, financial incentives, penalties | Clinician engagement in improvement based on trust, collaboration, professionalism, financial neutrality; Metric modesty recognizing many best practices yet to be defined/proven |
| More rules, requirements; target outlier physicians | Standardization with flexibility; learning from deviations |
| More time with patients | Better time spent with patients: offloading distractions, more efficient history collection/organization, longitudinal continuity, additional time to talk/think/explain; Easier access for patients to reach clinicians |
| Reflex changes in response to errors | Avoiding 'tampering': understanding/diagnosing difference between 'special cause' versus 'common cause' (random) variation |
4. UNCERTAINTY IN DIAGNOSIS¶
Given variations in patient presentations, illness evolution, and test performance, it is often not possible or practical to 'make' a definitive diagnosis, particularly in primary care early in the course of illness. Clinicians need to harness these uncertainties to: 1. Have enhanced situational awareness of where things can go wrong 2. Create safety nets to protect patients against harms from delayed diagnosis and misdiagnosis Terms that need to be part of vocabulary, thinking, and communications with patients include: - Preliminary diagnosis - Working diagnosis - Differential diagnosis - Deferred diagnosis - Undiagnosed illness - Diagnoses with uncertain or multifactorial etiologies - Intermittent diagnoses - Multiple/dual diagnoses - Self-diagnosis - Contested diagnosis Anxious patients worried about conditions (cancer, COVID-19, diagnoses to which relatives have succumbed) come seeking reassurance and may not welcome uncertain answers. Clinicians must work with patients, listen to and respect their concerns, take symptoms seriously yet modestly acknowledge limitations, tailoring the approach to patients' differing levels of health literacy, trust, and experiences with the health system.
5. DON'T MISS DIAGNOSES AND RED FLAGS¶
Uncertainty should not be a license for complacency. For diseases that: 1. Progress rapidly 2. Require specific treatments dependent on correct diagnosis 3. Have public health or contagion implications Clinicians need to be poised, and systems designed, to consider and pursue critical 'don't miss' diagnoses.
Examples of 'Don't Miss' Diagnoses¶
| Infections/Inflammation | Cardiac/Ischemic/Bleeding | Metabolic/Hematologic/Environme ntal |
|---|---|---|
| Spinal epidural abscess | Aortic dissection | Diabetes ketoacidosis |
| Necrotizing fasciitis | Leaking/ruptured abdominal aortic aneurysm | Hyperosmolar hyperglycemia |
| Meningitis | Pericardial tamponade | Myxedema/thyrotoxicosis |
| Endocarditis | Wolff-Parkinson-White | Addison's disease |
| Peritonsillar abscess | Prolonged QT | B12 deficiency anemia |
| Tuberculosis (active pulmonary, other) | Pulmonary embolism | von Willebrand's disease |
| COVID-19 infection | Tension pneumothorax | Hemochromatosis |
| Guillain-Barré syndrome | Acute mesenteric ischemia | Celiac sprue |
| Ebola infection | Esophageal/bowel perforation | Carbon monoxide, lead, pesticide poisoning |
| Temporal arteritis | Cerebellar hemorrhage | Food poisoning |
| Rhabdomyolysis | Spinal cord compression | Malignant hyperthermia |
| Angioedema | Testicular/ovarian torsion | Alcohol, benzodiazepine, barbiturate withdrawal |
| Ectopic pregnancy | Tumor lysis syndrome | |
| Retroperitoneal hemorrhage | Hypo-/hypercalcemia |
5.1 Red Flags Concept¶
Red flags or 'alarm symptoms' originated in guidelines for back pain but have been applied to many other problems (headache, red eye, swollen joint, abdominal pain, chest pain). Examples of widely cited red flags for back pain that should trigger consideration of more serious etiologies: - Fever - Weight loss - History of malignancy - History of intravenous drug use - Neurologic signs and symptoms Evidence-based medicine calls for better data on sensitivity, specificity, yield, and discriminatory ability of various 'red flag' clues; few have been rigorously evaluated. Nonetheless, clinicians find them useful as simple ways to reassure themselves and patients that common symptoms are, or are not, likely indicators of more urgent or serious pathology.
5.2 Overtesting and Overdiagnosis¶
Interwoven with challenges of not missing critical diagnoses is the problem of overtesting and overdiagnosis—performing unnecessary and potentially harmful tests whose benefit does not justify risks or costs, or that may lead to diagnoses that would never have caused symptoms or problems. Diagnosticians must carefully weigh this 'other side of the coin' of missed diagnosis to avoid such harms and expenses. Being more conservative in diagnostic testing should not be primarily about conserving resources, but about ensuring studies truly benefit patients while minimizing short- and longer-term harms.
6. DIAGNOSTIC PITFALLS¶
Learning from the missteps of those who have walked the path ahead is essential. By learning about commonly missed diagnoses and ways accurate, timely diagnosis went astray, clinicians can avoid similar mistakes. Anticipating potential for similar types of errors creates situational awareness of traps to avoid and contributes to learning from personal and collective patterns of mistakes. Example of common disease-specific diagnostic pitfall: In breast cancer diagnosis, ordering a mammogram for a woman with a palpable breast lump and, when the mammogram returns normal, reassuring her that cancer has been 'ruled out' by the negative test. Any unexplained mass or lesion palpable on physical examination needs assessment including further testing and biopsy where warranted. Large databases now have potential to track 'diagnosis outcomes'—whether new diagnoses emerge suggesting initial diagnosis was incorrect or diagnosis was suboptimally delayed. This should allow more rigorous focus on these cases, identification of contributing factors and recurring patterns, and systemwide improvement strategies.
Generic Types of Diagnostic Pitfalls¶
| Pitfall | Examples |
|---|---|
| Disease A mistaken for disease B (diseases often mistaken/misdiagnosed with each other) | (cid:127) Aortic dissection misdiagnosed as acute myocardial infarction (cid:127) Bipolar disorder misdiagnosed as depression |
| Misinterpretation of test result(s): False-positive or false-negative results with failure to recognize test limitations | (cid:127) Breast lump dismissed after negative mammogram (cid:127) Negative COVID-19 test early or late in course |
| Failure to recognize atypical presentation, signs, and symptoms | (cid:127) Apathetic hyperthyroidism (cid:127) Sepsis in elderly patient who is afebrile or hypothermic |
| Failure to assess appropriately the urgency of diagnosis: Urgency not appreciated and/or delays critical diagnoses | (cid:127) Compartment syndrome (cid:127) Pericardial tamponade (cid:127) Tension pneumothorax (cid:127) Sigmoid volvulus |
| Pitfall | Examples |
|---|---|
| Perils of intermittent symptoms or misleading evolution: Intermittent symptoms dismissed due to normal findings when initially seen | (cid:127) 'Lucid interval' in traumatic epidural hematoma (cid:127) Paroxysmal arrhythmias (cid:127) Intermittent hydrocephalus (Bruns' syndrome) |
| Confusion arising from response/masking by empiric treatment | (cid:127) Empiric treatment with steroids, proton pump inhibitors, antibiotics, pain medication erroneously masking serious diagnosis |
| Chronic disease or comorbidity presumed to account for new symptoms (especially in medically complex patients) | (cid:127) Septic joint signs misattributed to chronic rheumatoid arthritis (cid:127) Mental status change due to infection or medication misattributed to underlying dementia |
| Rare diagnosis: failure to consider or know (especially if urgent or treatable) | (cid:127) Many; fortunately, by definition, rare, but still warrant consideration |
| Drug or environmental factor not considered/overlooked: Underlying etiology causing/contributing to symptoms or disease progression not sought, uncovered | (cid:127) Ventricular arrhythmia related to QT-prolonging drug (cid:127) Achilles tendon rupture related to quinolone |
| Failure to appreciate risk factors for particular disease | (cid:127) Family history of breast, colorectal cancer not solicited and/or weighed in diagnostic evaluation or screening |
| Failure to appreciate limitations of physical exam (now with › telemedicine, missing physical exam entirely) | (cid:127) Overweighing absence of tenderness, swelling in deep vein thrombosis (cid:127) Missing pill-rolling tremor during telemedicine visit |
7. DIAGNOSIS SAFETY CULTURE¶
Just as diagnosing bacterial infections relies on proper culture medium, good diagnosis requires a healthy safety culture to grow and flourish. While clinicians may view 'safety culture' as too subjective to be important, this view is misguided. Multiple studies demonstrate adverse consequences from organizational cultures that inhibit openness, learning, and sharing and create climates where staff and patients are afraid to speak up when observing problems or having questions. Most importantly, patients need to be encouraged to question diagnoses and be heard, particularly when not responding to treatment as expected or developing symptoms inconsistent with diagnosis or representing possible red flags.
7.1 Safety Culture Assessment Domains¶
Safety measurement tools are validated staff surveys assessing: 1. Communication about errors: Staff willingness to report mistakes because they do not feel these are held against them 2. Openness and encouragement: To talk about hospital/office problems 3. Learning culture: Seeks to learn from errors and improve based on lessons learned 4. Leadership commitment to safety: Prioritizing safety over production speed and 'bottom line' by providing adequate staffing and resources to operate safely 5. Accountability and transparency: For following up safety events and concerns
7.2 Implications for Diagnostic Safety¶
Each generic culture attribute translates into specific implications for diagnostic safety: - Making it 'safe' for clinicians to admit and share diagnostic errors - Proactive identification, ownership, and accountability regarding error-prone diagnostic workflow processes (particularly around test results, referrals, and patient follow-up) - Leadership making diagnosis improvement a top priority based on recognition that patients and malpractice insurers report diagnostic errors as the leading patient safety problem - Mutual trust and respect for challenges clinicians face in making diagnoses - Caution in applying hindsight bias lens when judging what in retrospect might seem like an 'obvious' diagnosis that a clinician initially missed
8. HEALTH INFORMATION TECHNOLOGY AND THE FUTURE OF DIAGNOSIS¶
Clinicians now spend more time interacting with computers than with patients. This is especially true for diagnosis and will likely be more so in the future. Key activities are now computer-based: - Collecting patients' history (past and current) - Interpreting data to make diagnoses - Conveying diagnostic assessments (to team and to patients via open notes) - Tracking diagnostic trajectories as they evolve With telemedicine rise, even physical examination elements have been rerouted to electronic encounters, with important implications for diagnostic safety. While many complain computers have 'gotten in the way' of good diagnosis—distracting clinicians from quality listening time and miring doctors in notes filled with copied/pasted/templated information of questionable currency and accuracy—medicine needs to harness computer capabilities to improve diagnosis.
Areas Where Health Information Technology Has Potential to Help Improve Diagnosis and Reduce Errors¶
| Function | Examples |
|---|---|
| Facilitate collection/gathering of information | (cid:127) Quickly access past history from prior care at same and outside institutions (cid:127) Electronic collection of history of present illness, review of systems, and social determinant risks in advance of visits |
| Enhanced information entry, organization, and display | (cid:127) Visually enhanced flowsheets showing trends, relationships to treatment (cid:127) Reorganized notes to facilitate summarization and simplification and prevent items from getting lost |
| Generating differential diagnosis | (cid:127) Automated creation of lists of diagnoses to consider based on patient's symptoms, demographics, risks (cid:127) ChatGPT augmenting physician's diagnostic considerations |
| Weighing diagnoses likelihoods | (cid:127) Tools to assist in calculation of posttest (Bayesian) probabilities |
| Aids for formulating diagnostic plan, intelligent test ordering | (cid:127) Entering a diagnostic consideration (e.g., celiac disease, pheochromocytoma) and computer suggests most appropriate diagnostic test(s) and how to order |
| Access to diagnostic reference information | (cid:127) Info-buttons instantly linking symptom- or diagnosis-relevant questions to Harrison's, UpToDate chapters, references |
| Ensuring more reliable follow-up | (cid:127) Hardwiring 'closed loops' to ensure abnormal labs, missed referrals, worrisome symptoms are tracked and followed up |
| Support screening for early detection | (cid:127) Collaborative tools that patients, clinicians, and offices can use to know when due, order and track screening based on individualized demographics, risk factors, prior tests |
| Function | Examples |
|---|---|
| Collaborative diagnosis; access to specialist | (cid:127) Real-time posing/answering of questions (cid:127) Electronic consults; virtual co-management |
| Facilitating feedback on diagnoses | (cid:127) Feeding back new diagnoses (from downstream providers, patients) that emerge suggesting potential misdiagnosis/errors to clinicians, emergency rooms that saw patient previously |
8.1 Generative AI Considerations¶
With rise of generative artificial intelligence large language learning models, many look to computers to take over making diagnoses, answering patients' diagnostic questions, or resolving diagnostic dilemmas. Despite significant capabilities for image and data analysis, pattern recognition, creating clinical notes, and decision support including generating differential diagnoses, there are fundamental limitations, challenges, and unanswered questions related to data accuracy and how to incorporate human relational elements into AI-driven diagnostic processes.
9. PRACTICAL APPROACH: DIAGNOSTIC SAFETY QUESTIONS¶
In practice, there are frequent and meaningful opportunities for improving diagnosis in each of the three NAM-defined areas: 1. More reliable diagnosis 2. Timely diagnosis 3. Improved diagnosis-related communication with patients
9.1 Questions for Individual Patients¶
Clinicians should develop the habit of regularly asking themselves three questions about each patient being assessed: 1. What else might this be? (Forcing a differential diagnosis to be made) 2. What doesn't fit? (Making sure unexplained abnormal findings are not dismissed) 3. What critical diagnoses are important not to miss? (Injecting consideration of 'don't miss' diagnoses, red flags, and known pitfalls)
9.2 Questions for Systems¶
Each practitioner must recognize they work within a larger system. Questions to ask continually to maximize reliability and timeliness while minimizing potential for errors: 1. Do we have reliable 'closed loop' systems to provide reliable, ideally automated tracking and following up of patients' symptoms, abnormal laboratory or imaging findings, and critical referrals that we order? 2. What is the culture-of-safety climate in our organization, office, or clinic? 3. How does the electronic (or even paper) medical record as currently implemented help versus impair efficient, timely, accurate, and fail-safe diagnosis, and how can it be improved?
10. KEY POINTS & CLINICAL PEARLS¶
- Diagnostic errors affect 40,000-80,000 hospital deaths annually in the U.S.—this is a leading patient safety problem
- The three components of diagnostic error (NAM definition): (1) failure to establish accurate explanation, (2) failure to establish timely explanation, (3) failure to communicate explanation to patient
- Cognitive biases most commonly contributing to errors: premature closure, anchoring, confirmation bias, search satisficing, availability bias
- Diagnosis is a system property, not solely dependent on individual physician expertise—requires coordinated teamwork including the patient
- 'Red flags' are alarm symptoms that should trigger consideration of more serious etiologies (e.g., fever, weight loss, history of malignancy, neurologic signs in back pain)
- For every patient: Ask 'What else might this be?', 'What doesn't fit?', 'What critical diagnoses are important not to miss?'
- For systems: Ensure 'closed loop' follow-up systems, assess safety culture climate, optimize EHR support for diagnosis
- Terms to embrace uncertainty: preliminary diagnosis, working diagnosis, differential diagnosis, deferred diagnosis, undiagnosed illness
- Overtesting and overdiagnosis can be as harmful as missed diagnosis—judicious test ordering is essential
- Safety culture transformation, reliable follow-up/feedback, learning from errors, leveraging health IT, and partnering with patients are essential for diagnostic excellence
- Hindsight bias: Be cautious in judging what in retrospect might seem like an 'obvious' diagnosis that was initially missed