Structured case reviews for organizational learning about diagnostic vulnerabilities: initial experiences from two...

Area of Science:

• Healthcare Improvement
• Patient Safety
• Diagnostic Error Reduction

Background:

• Effective processes for identifying and learning from opportunities for improvement (OFI) are crucial for enhancing diagnostic safety.
• Many healthcare organizations struggle to implement robust systems for capitalizing on learning opportunities.

Purpose of the Study:

• To describe two parallel initiatives to create triggered case review programs for identifying OFI.
• To identify generalizable lessons learned from establishing and operating these review systems.

Main Methods:

• Two organizations independently developed triggered case review programs using a five-step process: identifying triggers, establishing review panels, developing review systems, conducting reviews, and providing feedback.
• The programs involved analyzing cases to identify provider and system-level OFI.

Main Results:

• Site 1 identified 112 OFI in 184 reviews (61%), with a mix of provider and system OFI.
• Site 2 identified 105 OFI in 346 cases (30%), primarily focusing on system OFI.
• Common OFI themes included test result management and inter-team communication, particularly in peri-procedural care and with consultants.

Conclusions:

• Peer review of cases facilitates organizational learning and calibration of diagnostic and management decisions.
• Sharing cases within review groups cultivates a culture conducive to open discussion of OFI.
• Diagnostic safety reviews can identify opportunities that complement existing organizational improvement efforts.