10 practices to address diagnostic errors: Joint Commission

Researchers have developed a list of 10 high-priority safety practices to help healthcare organizations address diagnostic errors, based on a comprehensive literature review and input from additional experts. 

The list of practices was published in the November issue of The Joint Commission Journal on Quality and Patient Safety. To start, researchers identified possible practices based on literature reviews, reports from national and international organizations, and interviews with quality and safety leaders. To prioritize the top 10 practices, a Delphi panel was conducted that surveyed experts such as patient safety experts and diagnostic errors researchers, followed by an online expert panel. 

"The prioritization process considered impact on patient safety and feasibility of practice implementation within a one- to three-year time frame," researchers said. 

Ten high-priority practices for diagnostic excellence, as outlined in the report: 

1. Organizational leadership builds a "board-to-bedside" accountability framework

2. A just culture and psychologically safe environment for diagnostic safety

3. Creation of feedback loops to increase information flow

4. Multidisciplinary perspectives, including cognitive science and human factors, in analysis of diagnostic safety events 

5. Patient and family feedback to identify and understand diagnostic safety concerns

6. Patient review of their health records and mechanisms in place to help patients understand, interpret and/or act upon diagnostic information 

7. Prioritization of equity in diagnostic safety efforts by segmenting data to understand root causes and implementing strategies to address and narrow equity gaps

8. Standardized systems and processes to encourage direct, collaborative interactions between treating clinical teams and diagnostic specialties

9. Standardized systems and processes to ensure reliable communication of diagnostic information between care providers and with patients and families during handoffs and transitions

10. Standardized systems and processes to close the loop on communication and follow up on abnormal test results and referrals

View the full report here

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