Transitions of care represent a vulnerable moment for patients and families with high potential for diagnostic error, regardless of the care contexts between which the transition occurs. Although handoffs between shifts have been largely recognized as vulnerable moments for patient care, transitions between other contexts have not been as readily recognized as having such high potential for diagnostic error.
Each unique context carries its own risks for diagnostic error. Table 1 highlights and summarizes specific strategies that can help mitigate diagnostic error at each transition.
Table 1. Care transitions, sources of error, and potential mitigating strategies
Care Transition |
Latent Failures Contributing to Error |
Potential Mitigating Strategies |
---|---|---|
ED to hospital |
Encounter brevity |
Standardization of processes |
High patient acuity |
Artificial intelligence/machine learning (AI/ML) prediction tools |
|
High patient volumes |
Availability of timely expert consultation |
|
Diagnostic uncertainty |
Explicitly mentioning diagnostic uncertainty |
|
Nonlinear care pathways |
Uncertainty communication checklists |
|
Lack of shared mental model |
Standardized communication tools |
|
ICU to ward |
High patient acuity |
Standardization of processes |
High patient complexity |
AI/ML prediction tools |
|
Diagnostic uncertainty |
Patient and family involvement |
|
Lack of structured handoffs |
Standardized communication tools |
|
Lack of family engagement |
Explicitly mentioning diagnostic uncertainty |
|
OR to ICU |
Encounter brevity |
Standardization of processes |
High patient acuity |
Standardized communication tools |
|
Lack of shared mental model |
Standardized communication tools |
|
Coordination between multiple specialties |
Standardized communication tools |
|
Inpatient to outpatient |
Evolving diagnoses |
Standardization of processes |
Lack of shared mental model |
Standardized communication tools |
|
Lack of structured handoffs |
Patient and family involvement |
|
Inadequate or incomplete documentation |
Education about diagnostic error |
|
Multiple care transitions |
Personal and system diagnostic calibration |
Although each transition has had some research focusing on improving the transition of care between contexts, the explicit goal of reducing diagnostic error has not been studied. Tools such as Calibrate Dx must be applied to help both individual clinicians and larger health systems evaluate and calibrate their own diagnostic performance. Moreover, interventions focused on mitigating diagnostic error at each transition have largely not scaled up implementation across multiple institutions nationally. Research is needed to more explicitly study the impact of these interventions on diagnostic error and to scale up and nationally implement effective tools to mitigate diagnostic error.