Avoiding diagnostic errors: Strategies and root causes

July 23, 2018

No one wants to make an error, let alone an error that is life threatening. How can individual or group providers create a culture of safety within their practices?

Drs Neuspiel and Schuman’s article, Prevent medical errors in your practice, describes strategies that support a culture of safety in ambulatory practices by focusing on prevention of diagnostic and medication errors. The authors’ imperative to provide safe and effective care is one all providers must take seriously. No one wants to make an error, let alone an error that is life threatening. How can individual or group providers create a culture of safety within their practices? Drs Neuspiel and Schuman recommend conducting quality improvement projects, and when an error occurs, a root cause analysis with the outcomes of initiating and evaluating the effectiveness of interventions in order to prevent diagnostic errors and maintain safety in medication administration. In 2017, Dr Schuman described ways to avoid prescribing errors in clinical practice and I commented on his article at that time with a call to “Revisit the ‘Five rights’ to Avoid Medication Errors.” In this commentary, I am addressing medical diagnostic errors.

Instill diagnostic reasoning

As an educator of students in a pediatric nurse practitioner program, I have learned first hand the value of problem-based education for students to acquire diagnostic reasoning skills with the overarching goal of preventing diagnostic errors. Examining cases through the lens of problem-based learning strategies demands that both the educator and students commit to searching the evidence to discover the answers for the numerous ‘why’s’ embedded within each problem. For example: ‘Why’ is the child/adolescent presenting with these symptoms? ‘Why’ is the backstory important to the investigation? ‘Why’ should diagnostic tests be ordered or not ordered? ‘Why’ investigate the pathophysiology and pharmacological treatment? ‘Why’ is a particular treatment plan ordered? And the ‘why’ questions continue on and on.

Educators can no longer teach students everything they need for success on Board examinations  and in clinical practice. Students can no longer be passive learners. Educators must facilitate student discovery and excite students to be inquisitive, active learners searching for scientific evidence to support all decisions. And yes, at first, there is learner resistance and that, in and of itself, is challenging. Students want to know ‘what is on the exam;’ ‘what should I know;’ and ‘what should I read?’ Throw away the what and ask the ‘why.’ Once students learn the processes of investigative discovery, they not only become excellent learners, but they also excel at the process and can ‘think through’ any case using scientific foundations of evidence-based resolutions. Problem-based education is the key to prevention of diagnostic errors. 

Clinical educators: Continue to challenge students

An excellent example of why clinical educators need to also challenge students using problem-based educational strategies is revealed in the article authored by Ms Nierengarten, Primary Immunodeficiency: When recurrent infections signal something more. The author discusses the problems of practicing within a narrow focus when a child presents with recurrent infections and why the narrow focus may lead to medical diagnostic errors. Clinical educators must use problem-based strategies to challenge themselves and students to search deeply to fully examine all possible aspects of the presenting problems.

Demand understanding

 

For years, educators have written measureable objectives/outcomes avoiding using the word understand. The question has always been how can we measure whether a student understands a concept? The outcomes from the processes of investigative discovery demanded of those involved in problem-based learning is how we, as educators, can determine if each student understood the problem and avoided making the unacceptable medical diagnostic error.