Nearly 7 in 10 errors occur during the testing process, such as ordering, collecting, processing, and obtaining and communicating results, according to an ECRI analysis. The organization analyzed more than 3,000 patient safety adverse events and near-misses reported by healthcare workers.
Of those errors, more than 23% were due to a technical or processing error, “such as the misuse of testing equipment, a poorly processed specimen, or a clinician lacking the proper skill to conduct the test,” a Sept. 5 news release said. “Another 20% of testing errors were a result of mixed-up samples, mislabeled specimens, and tests performed on the wrong patient.”
Twelve percent of diagnostic errors occurred in the monitoring and follow-up phase, and about nine percent happened during the referral and consultation phase, including miscommunication.
In some cases, productivity pressures restrained clinicians from exploring all options or from consulting other experts. To reduce the prevalence of diagnostic errors, the ECRI recommends healthcare leaders focus on the total systems safety approach and human factors engineering, the organization said.
“It’s a common misconception that if a patient has a missed or incorrect diagnosis, their doctor came up with the wrong hypothesis after having all the facts,” ECRI president and CEO Marcus Schabacker said in a statement. “That does happen occasionally, but we found that was tied to less than 3% of diagnostic errors. What’s more likely to break the diagnostic process are technical, administrative and communication-related issues. These represent system failures, where many small mistakes lead to one big mistake.”
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