The hospital discharge, when patients transition from the inpatient to outpatient setting, is perhaps the setting where diagnostic error and diagnostic uncertainty have been most well recognized and well studied. In one study, 49 percent of patients experienced at least one medical error after discharge, related to a variety of causes, including medication, test results, and diagnostic workups.86
Medical students are taught from their early clinical foundation the importance of preparing for a high-quality and safe discharge to prevent readmissions, medication-related adverse events, and diagnostic error. The Joint Commission recognizes and codifies that discharge summaries are a required part of the medical record and must be completed within 30 days of discharge.87 Interventions related to measuring and preventing postdischarge error have largely focused on communication and coordination of care.88 This section will review inpatient-to-outpatient handoff-specific contributors to diagnostic errors and uncertainty and discuss strategies to mitigate diagnostic errors and uncertainty.
Inpatient-to-Outpatient Handoff-Specific Contributors to Diagnostic Errors and Uncertainty
Patients transitioning from the inpatient to the outpatient setting are also vulnerable to diagnostic error as the discharging teams' provisional or working diagnoses may evolve posthospitalization. Moreover, patients and families often have limited engagement in the decision to discharge. Communication between inpatient and outpatient providers is quite limited and often only consists of the written discharge summary. Lastly, discharge summaries are often unavailable, not timely, too brief or too long, unstandardized, or not informative enough, especially after high-acuity complex inpatient hospitalizations.
Deficits occur in both communication and information transfer at the inpatient-to-outpatient transition, with available discharge summaries often omitting critical information, such as diagnostic test results, test results pending at discharge, and discharge medications.89 During ICU stays, when patients experience multiple care transitions described above (both ICU-to-ward and inpatient-to-outpatient), the potential for diagnostic error can be further magnified, and the standardized discharge summaries can be especially inadequate.90
Although the literature on the inpatient-to-outpatient transition in general is robust, the literature specifically focusing on diagnostic error at this transition is much more limited. One prospective cohort study of unplanned 7-day and 30-day hospital readmissions found that diagnostic error may have contributed to 10.6 percent of 7-day readmissions in this high-risk cohort.91
One retrospective cohort study of unplanned 7-day readmissions specifically used a two-physician diagnostic error review and adjudication process to categorize diagnostic error. The incidence of diagnostic error was 5.6 percent, with the most common errors related to radiology/laboratory testing and clinicians' diagnostic reasoning.92 The most common contributing factors to clinical reasoning errors were failure or delay in ordering needed diagnostic tests, erroneous interpretation of tests, and inappropriate consideration or prioritization of diagnoses.
Strategies To Mitigate Diagnostic Errors and Uncertainty at Inpatient-to-Outpatient Transitions
The inpatient-to-outpatient transition has been the most studied, and a variety of structured improvements have been made to standardize this process, including a focus on diagnostic error. Most of these interventions focus on improved discharge processes and documentation, improved verbal handoffs and including patients and families in the process, and improved awareness and education about diagnostic errors.
Several interventions have focused on standardizing and improving the complexities of the discharge process. AHRQ developed an evidence-based resource to improve the safety of the inpatient-to-outpatient transition and engage patients and families in discharge planning through a novel IDEAL Discharge Planning strategy.93 This systematic framework focuses on:
- Including patients and families as full partners in discharge planning,
- Discussing with patients and families key areas to prevent problems at home,
- Educating patients and families about the patient's condition and the discharge process,
- Assessing how well doctors and nurses explain the diagnosis using teach-back, and
- Listening to and honoring the patient and family's goals and preferences.
These strategies empower the patient and family's involvement in the diagnostic journey as well as the discharge process, thus engaging patients and families as partners throughout.
Similarly, the Warm Handoff Plus tool is a patient safety strategy that ensures that patients and family are present for a warm face-to-face verbal handoff between two members of the healthcare team.94 It was originally designed to be conducted within the primary care practice but could also be applied at the inpatient-to-outpatient transition if applicable.
Unfortunately, a warm handoff is rarely possible between the inpatient and outpatient contexts, and written discharge summaries are often the only communication that occurs between inpatient and outpatient teams. Thus, improving and standardizing discharge summaries is an essential component of mitigating diagnostic error at the inpatient-to-outpatient transition.
In 2007, the Transitions of Care Consensus Conference recommended adoption of standardized discharge summary elements with specific factors included such as patients' goals of care and clear delineation of responsibilities for outpatient postdischarge patient care-related tasks.95 Followup efforts have focused on designing and implementing enhanced discharge summary templates to focus on reducing redundant documentation and promoting clinician satisfaction.96
Various studies have shown that electronic discharge summary templates and other electronic tools were associated with improved timeliness of communication with outpatient physicians and improved communication of potential diagnostic errors, such as discussing test results pending at discharge.97–100
While many interventions focus on improving the discharge process and communication related to discharge, other interventions, which could be used in any healthcare setting, focus on educating clinicians about diagnostic error. A systematic review of cognitive interventions to reduce diagnostic error across healthcare settings found that different modalities all helped reduce cognitive errors in diagnosis. However, most interventions were not tested directly for error reduction in clinical practice. Interventions included simulation-based training, improved feedback and education, reflective practice, metacognitive review, and use of cognitive aids.101
One example of a real-life ambulatory cognitive intervention was the institution of a diagnostic pause in the ambulatory care setting, which was found to influence clinicians to modify initial working diagnoses without adding significant extra time burden.102 The inpatient-to-outpatient care transition is another opportunity to use tools such as Calibrate Dx for both individual clinicians and health systems to evaluate and calibrate diagnostic performance.
In conclusion, while the inpatient-to-outpatient transition poses challenges when it comes to diagnostic error, structured tools have been developed to standardize communication, improve patient and family engagement, and improve education about diagnostic error at this key transition.
