Keeping key diagnostic drivers top of mind in the challenging emergency department environment

We know from new research that just three diagnostic errors are the cause of almost 75% of patient harm—not to mention $1.8 billion in malpractice payouts—in the emergency department (ED): misdiagnosed cancers, vascular events, and infections.

But what if there were a way to help improve the risk profile here?

I recently had the opportunity to speak with Dr. Daniel Sullivan, whose illuminating work in the areas of patient safety and healthcare risk management spans three decades and dozens of facilities. I invited him to write on this topic and help us better understand how documentation guidance can help overcome these core risks to patient safety in the ED.

Improving risk, safety, and quality: a guest blog by:
Daniel J. Sullivan, MD, JD, FACEP, President & CEO |
The Sullivan Group

Diagnostic uncertainty is a fact of life in the practice of emergency medicine (EM). In EM, the failure to make an accurate and timely diagnosis is the most common medical error and cause of patient injury and exposure to litigation. Although there are other safety issues, the failure to diagnose is by far the number one issue for any EM risk and safety program.

The Sullivan Group (TSG) has studied the failure to diagnose in EM for three decades, working with some of the world’s largest healthcare organizations. The critical issue is that there is significant variability in practitioner evaluation of key diagnostic elements in the highest risk patient presentations. TSG has been able to demonstrate that reduction in that variability and alignment around those key diagnostic drivers can result in dramatic reductions in both the failure to diagnose and the frequency of litigation.

Examples of diagnostic drivers include the following:

  1. In an adult patient with chest pain, the practitioner must assess whether there has been movement or migration of the pain into the low back or abdomen. Although this finding points directly to the diagnosis of acute aortic dissection, in a TSG analysis of over 15,000 chest pain patients, movement or migration of pain was not addressed or documented in over 50% of adult chest pain presentations.
  2. In a child with fever, the practitioner must be aware of the child’s immunization status. Immunizations lacking or not up to date drives a critical thought process relating to a serious bacterial illness. In a TSG analysis of over 10,000 children with fever, immunization status was missing in over 20% of cases.
  3. In a TSG analysis of 90,000 patients, 9,000 were found to have a very abnormal vital sign; 16% of those patients were discharged home without a single repeat of the abnormal vital sign.

There are many similar examples of missed opportunities across the spectrum of high-risk presentations. Addressing key diagnostic drivers creates opportunities to decrease diagnostic uncertainty and reduce the failure to diagnose. So how do we support practitioners’ cognitive processes to harness those opportunities?

Fortunately, the solution is not complicated. The three issues above are far more addressable when the practitioner keeps them front of mind during the patient encounter. But there’s the rub! How to keep these key diagnostic drivers front of mind in the challenging environment of the emergency department.

The answer is real-time decision support available in the practitioner’s workflow during the patient encounter. TSG has partnered with Nuance Healthcare to build these key diagnostic drivers into a program called Dragon Medical Advisor (DMA) ED Guidance. As the practitioner creates a medical record (via dictation, typing or otherwise), DMA continuously processes the ED note and suggests those missing key elements of the history, physical exam and medical decision-making critical to forming an appropriate differential diagnosis for high-risk conditions.

DMA recognizes when those elements have been addressed and retires them from the list. It is, in essence, an interactive checklist. Designed for efficiency, with no change or interruption to the workflow, the practitioner merely completes the diagnostic process, leveraging the ED Guidance as needed. When the DMA window is empty, the practitioner has addressed those diagnostic elements most critical to getting to an appropriate differential diagnosis. High reliability at its best!

This is a new and exciting program that can dramatically impact risk, safety and quality. It is a proven approach that now harnesses the power of Dragon Medical One and Dragon Medical Advisor.

You can learn more about this topic here: Nuance-Sullivan Group press release.

About Michael Clark

Michael Clark is the senior vice president and general manager for Provider Solutions within Nuance’s Healthcare division, leading EHR Services, clinical documentation creation and improvement. A results-driven, accountable leader, Michael aligns organizations to prioritize the customer experience, honor the product roadmap, and execute against the company vision. He has more than 20 years of experience in the healthcare market and a breadth of experience driving and transforming global teams, products, and services. Prior to joining Nuance in 2016, Michael held several executive leadership roles at healthcare organizations including Evariant and MedQuist. Michael holds a B.A. in Marketing and International Business from Miami University and MBA from the University of Miami School of Business.