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.
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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.
Diagnosis Error Evaluation and Research (DEER) Taxonomy
Locates where in the diagnostic process and error may have occurred. This can help prioritize the most frequent and vulnerable failure points.
DOWNLOAD PDFReliable Diagnosis Challenges (RDC) Taxonomy
Identifies factors that may have contributed to make a diagnosis difficult. This can provide a framework for understanding and conducting a systematic analysis rather than focusing on an individual’s decision making.
DOWNLOAD PDFCognitive Errors Taxonomy
These common cognitive biases can contribute to diagnostic errors. They can be used to categorize, track, and educate staff about specific vulnerabilities.
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