Diagnostic errors occur at the intersection of diagnostic delays, diagnostic process failures, and adverse outcomes. Not all process failures lead to misdiagnosis. Likewise, failures or delays may not be the result of any identifiable process errors. Cases that fall at the intersection of delay, process failure, and adverse outcomes are most ripe for quality improvement interventions.

  • Diagnostic error case collection form
    A sample tool for provider organizations to adapt for their own internal learning and improvement activities.

Case review tools are used to analyze and identify the causes and contributors to missed and delayed diagnoses, regardless of whether harm occurred. Analyzing cases is a meaningful and interactive activity for health care providers to systematically explore and understand why an error happened. Over time, trends and patterns emerge across cases that can be targets for improvement work.