Foundations of safety improvement

Sustained diagnostic safety improvement is woven into routine operations by working with the human and operational factors that organizations need to balance to achieve safe, reliable care:

  1. High-functioning teams that have the awareness, training, and psychological safety they need to carry out their respective roles.
  2. Timely, actionable information about performance from diverse sources, including those on the frontlines — clinicians and staff, and patients and families.
  3. Operational capacity to recognize and solve problems routinely and continuously.
  4. Leadership committed to and actively engaging frontline staff and patients in improvement work within a culture of safety.

A continuous improvement system empowers clinicians and staff to ‘see and say’ concerns about operations and culture, ‘solve’ problems, and ‘spread’ solutions. Applying this to diagnostic safety, organizations need to be able to identify diagnostic errors, engage in safe and meaningful discussion of problems, support people to learn, and embed systemic improvements.

Diagnostic error case reviews

Diagnostic error case reviews can help identify the root causes of errors, reduce liability, and improve overall patient safety. By developing targeted improvement interventions after careful discussion and analysis, organizations can reduce the risk of future errors and improve the quality of patient care. This requires a process to report or detect diagnostic errors, a non-punitive venue for discussion and learning, a commitment to problem solving, and resources to make change.