Diagnostic error can be a blind spot in the patient safety field, according to the National Academy of Medicine.1 An underrecognized and high-risk moment in patients’ diagnostic journeys can occur at key intra- and perihospital transitions of care:
- From the emergency department (ED) to the ward,
- From the operating room (OR) to the postoperative area,
- From the intensive care unit (ICU) to the ward, and
- From the inpatient to the outpatient context (Figure 1).
Figure 1. Transitions of care with potential for diagnostic error
In healthcare and other industries, transitions of responsibility and handoffs are widely recognized as high-risk times when the potential for cognitive errors is high.2 Not only do patients and families experience a transition of their multidisciplinary care team of physicians, nurses, and other providers, but also these providers may be at high risk for anchoring bias and other cognitive errors in these moments.
Each transition of care has certain underlying context-specific factors contributing to diagnostic errors. For instance, the high volume of encounters in the ED, the high acuity of encounters in the ED and ICU, and the changing of team members across contexts may each contribute to errors differently in these settings. Cognitive errors can include:
- Faulty hypothesis generation (such as failing to consider rare diseases or atypical presentations of common diseases),
- Faulty context formation (seeking rarer diagnoses),
- Faulty information gathering,
- Anchoring bias (the tendency to rely too much on the first piece of information received), and
- Faulty verification of hypotheses.
Moreover, transitions of care are high-risk times that often involve medical complexity and diagnostic uncertainty,3 both of which must be explicitly managed by clinicians4 and communicated to patients and families. In addition to cognitive errors of omission and commission, communication errors may follow similar patterns and are particularly relevant to diagnostic error.
Improving transitions of care has been well studied and prioritized at a national level. In fact, in 2013, the Joint Commission identified seven foundations critical for ensuring safe and effective transitions from one healthcare setting to another, including:
- Leadership support,
- Multidisciplinary collaboration,
- Early identification of patients and clients at risk,
- Transitional planning,
- Medication management,
- Patient and family action and engagement, and
- Transfer of information.5
However, few strategies focus specifically on reducing diagnostic error during transitions of care.
To improve diagnostic safety at transitions of care, this issue brief examines the existing evidence base on how to improve diagnostic safety at intrahospital care transitions, from using data analysis tools to using structured communication frameworks. For each care transition, we will examine (1) context-specific contributors, (2) handoff or transition-specific contributors, and (3) recommended strategies to prevent and mitigate diagnostic errors and uncertainty.
