Page 9 - 2022 Risk Basics - Systems

SVMIC Risk Basics: Systems

ensure that any patient data and information that may require action are
delivered and communicated to the right individuals, at the right time, and
through the right mode, in order to allow for interpretation, critical review,

reconciliation, initiation of action, acknowledgement, and appropriate

documentation. Failures to close the loop are multifactorial and range
3
from a test not being performed at all, to a test not performed as ordered,
to the results not being returned to the clinician, to the clinician failing

to acknowledge those results. Each of these links in the chain of events

creates the potential for a break. Any failure to close these loops holds
the potential for patient harm through delayed, missed, or incorrect
diagnoses.
4

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. The study estimated that approximately 12 million adults in
5
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.

3 Partnership for Health IT Patient Safety. “Health IT Safe Practices for Closing the Loop.” Plymouth Meeting
(PA): ECRI Institute; 2018. Also available at: https://www.ecri.org/Resources/HIT/Closing_Loop/Closing_the_
Loop_Toolkit.pdf
4 The Physicians Report, Spring 2021, Physicians Report. https://www.phyins.com/sites/default/files/images/
magazine/Physicians%20Report-Spring-2021-Final.pdf
5 https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/Improving_diagnosis_
flyer.pdf

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