Diagnostic error was found to be one of the most prominent patient safety risks at the Sociedade Beneficente Israelita Brasileira Albert Einstein (SBIBAE), a tertiary care health system in São Paolo, Brazil. This health system consists of five high-complexity hospitals, two private (with 746 beds) and three public (with 889 beds) and provides both inpatient and outpatient care. The health system uses an anonymous incident reporting system, enabling employees to report potential adverse events, near-misses, or areas of risk across the entire health system.
Over the past 8 years, a specialized team made up of nurses, doctors, and medical specialists has analyzed these adverse events using the Root Cause Analysis and Action (RCA2) methodology.1 An analysis of 276 severe and catastrophic adverse events from 2016 to 2022 found that diagnostic errors contributed to 23 percent of all events.
The analysis led health system leaders to identify the diagnostic process as a critical issue that needs to be addressed to improve patient safety. To ensure the implementation of actions and interventions to reduce diagnostic safety events, we created a new Diagnostic Excellence Program with the endorsement of the institution's leadership. This program aimed to integrate and prioritize several fragmented initiatives across the institution and provide them with support.
To inform the development of the Diagnostic Excellence Program, we first conducted a survey-based assessment of physician perspectives on the culture of diagnostic safety at our institution. This case study describes how we used our survey to create an initial approach to developing and implementing a program to recognize and address diagnostic errors. The survey was adapted from AHRQ’s Medical Office Surveys on Patient Safety Culture® (SOPS®) Diagnostic Safety Supplemental Item Set.2