Page 10 - 2020 Risk Reduction Series Effective Systems_Part 1_Flipbook

SVMIC Risk Reduction Series: Effective Systems

review of professional liability claims from across the United

States shows that diagnosis-related claims account for a higher
percentage of dollar costs than any other category. Diagnostic

errors are the leading type of paid medical malpractice claims;
they’re almost twice as likely to have resulted in a patient’s

death compared to other claims and represent the highest
proportion of total payments. There are several key studies

that examine the most commonly misdiagnosed conditions.
One of those studies was published in 2014, and it was partially

funded by the Agency for Healthcare Research and Quality.
1
The study estimated that approximately 12 million adults in the

United States could experience an outpatient diagnostic error
each year. Of those, 46 percent involved both system-related

and cognitive factors. The majority of diagnostic errors are
preventable, yet they are a significant contributor to patient

injury and death. The diagnostic process typically involves
multiple stages of gathering and synthesizing information as a

result of observations. However, knowledge deficit on behalf of
the physician is not the most prevalent factor associated with

diagnostic error.

Errors in medical decision-making are often a result of many
factors including faulty data gathering, incomplete synthesis

of data, failure to consider differential diagnoses, and defective
systems and processes. This course will examine case studies

where systems and processes contributed to patient harm. All
names mentioned within the case studies have been changed.

The objective is to design systems and processes to ensure
that they reliably “close the loop” between the ordering of tests

or specialty referrals and the return of that information back

1 https://psnet.ahrq.gov/perspectives/perspective/169

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