Quality Assurance Impact of Diagnostic Discrepancies
Justin Cuff, Teri Longacre, Daniel A Arber. Stanford, Stanford, CA
Background: The landmark Institutes of Medicine report, 'Too Err is Human', launched a successful decade of patient safety initiatives and seeded an emerging discipline dedicated to studying diagnostic error, an important, but overlooked aspect of patient safety. We set out to observe how pathology processess, at the inter-institutional transfer of care, can contribute to reductions in patient harm. Understanding discrepancies, in relation to the clinical context, should suggest relevant areas for process optimization.
Design: Patient's transferring care to Stanford are required to have their slides reviewed prior to undergoing treatment. We compared 773 diagnoses spanning a four month period by constructing a relational database, SPIDeR (Stanford Pathology Inside/Outside Database Review tool), containing scanned PDF of outside reports, and the corresponding diagnosis and comment fields from the pathology database. We examined:the number of diagnostic procedures submitted with the referred material, size and practice type of the originating institution, organ system, diagnosis, prior second opinion, type of outside testing, additional ancillary studies and the clinical significance and reason for disagreement.
Results: We found that 9% of cases had a discrepancy in diagnosis, when comparing the initial working diagnosis to the second opinion (subject to revision pending resolution of diagnostic changes of uncertain signficance). In 3% (n=21) of cases a major discrepancy, expected to alter treatment, was identifed. Significant differences in discrepancy rates were found between organ systems (p<0.01) although discrepancies were identified in nearly all major organ systems. Gynecologic cases had the highest rate of discrepancy at 37%, dermatology cases 26%, and genito-urinary cases were 19% discrepant. The most common reason for a discrepant diagnosis was disagreement about classification.
73% of the referred cases represented a single procedure, 25% represented 2-3 different procedures. Additional testing was performed on 10% of the cases, and 5.4% of the cases had already been seen by a second consultant.
Conclusions: Diagnostic review generates a significant amount of discrepancy and impacts clinical management. Discrepancies are more common in some case types but may not provide reliable predictors to pre-select cases for review.
Category: Quality Assurance
Monday, March 19, 2012 1:00 PM
Poster Session II # 244, Monday Afternoon