Risk Insight 14 - Safer Diagnosis

NOVEMBER 2011

Risk insightSafer DiagnosisImproving the diagnostic process to reduce risks to patients

http://www.vmia.vic.gov.au

introductionIn the clinical setting, a range of variables can contribute to misdiagnosis, and missed or delayed diagnoses. Diagnosis in clinical care refers to the process of classification of a patient’s illness into distinct categories, allowing clinical decisions about treatment and prognosis to be made.

The diagnostic process varies for different clinical conditions. Patient history and/or physical examination are key elements of the process. These may be supplemented and facilitated by the judicious use of investigations.

Diagnosis may be performed by a variety of healthcare professionals including medical, nursing, allied health and ancillary providers. The diagnostic process involves the provider gathering information from the patient and others, usually from a physical examination of the patient and often from the results of medical tests performed on the patient1.

Misdiagnosis, missed diagnosis and delayed diagnosis (collectively referred to in this document as ‘misdiagnosis’) are common causes of medico-legal claims and have been repeatedly identified as areas in which there are potential for better risk management and quality improvement.

The Victorian Managed Insurance Authority (VMIA) identified the issue of risk and improvement in the diagnostic process as a priority topic faced by its dual medical indemnity and clinical risk management responsibilities. The VMIA convened a roundtable on 14 September 2011 with the purpose of identifying gaps, risk management issues, and potential improvement projects relating to adverse events associated with the diagnostic process.

The roundtable was facilitated by Dr Heather Wellington of DLA Piper. A background paper, informed by discussions with many of the participants before the roundtable, was prepared by Dr Kelly Shaw.

This Risk Insight document summarises interviews with participants conducted before the roundtable and discussion at the roundtable itself.

Dr Heather Wellington, Facilitator, and Roundtable participants

2 | Risk Insight safer Diagnosis www.vmia.vic.gov.au

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This document has been prepared as the basis for further discussion between the VMIA and health sector stakeholders about priority areas and projects which the VMIA could progress in collaboration with its clients through its Risk Management Partnership Program.

The VMIA would like to thank the interviewees and participants who have given generously of their time, experience and intellect to this important topic.

Background – Medical indemnity claimsResearch and clinical evidence indicates that misdiagnosis contributes between 35 to 50 percent of all medical indemnity claims.

The rate of misdiagnosis depends on the medical specialty involved. Diagnostic risks are not limited to the emergency department of hospitals. They arise throughout the healthcare system and are also likely to be prevalent in outpatient/consulting and inpatient settings. The data currently available do not allow reliable identification of trends in diagnostic risks or adverse events associated with diagnostic processes. Participants agreed, however, that there is considerable room to improve diagnostic processes in the Victorian healthcare system, thereby reducing patient and system-wide risks.

Across the Victorian Public Sector, approximately 1,200 claims are reported to the VMIA annually. Medical indemnity represents about 45 percent of claims reported and 55 percent of total net claim payments.

Misdiagnosis and delayed/missed diagnosis represents approximately 30 percent of the most frequently reported incident type to the VMIA.

These factors combine to make misdiagnosis a risk management priority for the VMIA, as part of its objective to reduce both preventable adverse events (Clinical Risk Management Strategy 2010-2013) and the total cost of risk to the State of Victoria.

Professor Anne Maree Kelly, Emergency physician and academic head of Emergency Medicine, Western Health; Director Joseph Epstein Centre for Emergency Medicine Research, Western Health

The following senior health professionals, managers and VMIA representatives participated in the roundtable and prior consultation:

• A/Professor Tim Baker, Director of the Centre for Rural Emergency Medicine, Deakin University

• Mr Martin Botros, Manager Policy, Office of the Coroner, and Board Member, Eastern Health

• Professor Peter Cameron, Head of Prehospital, Emergency and Trauma Group, Monash University Department of Epidemiology and Preventive Medicine, and Academic Director, The Emergency and Trauma Centre, The Alfred

• Ms Filomena Ciavarella, Director Quality and Risk, Austin Health

• Dr Carmel Crock, Director of Emergency Department, Royal Victorian Eye and Ear Hospital

• Dr Anthony Felber, Radiologist, Epworth Health

• Ms Lynette Ford, Director of Quality Patient Safety and Consumer Liaison Unit, Melbourne Health

• Professor Anne Maree Kelly, Emergency physician and academic head of Emergency Medicine, Western Health; Director Joseph Epstein Centre for Emergency Medicine Research, Western Health

• Dr Marcus Kennedy, Director, Adult Retrieval, Ambulance Victoria

• Ms Vanessa Lane, Manager Quality, Safety and Patient Experience, Department of Health

• Dr Alastair Mah, Fellow in Medical Management, Melbourne Health

• A/Professor Ian McInnes, General Surgeon and Member of the Victorian Surgical Consultative Council

• Ms Samantha Reid, Acting Clinical Risk Manager, VMIA

• Ms Trudy Robson, consumer and member, Australian Institute of Patient and Family Centred Care

• Dr John Royle, Vascular Surgeon, member, the Victorian Surgical Consultative Council

• Professor Stephen Stuckey, Director, Diagnostic Imaging and Head of MRI, Southern Health

• Dr Helen Stergiou, Deputy Director, The Emergency and Trauma Centre, The Alfred.

www.vmia.vic.gov.au Risk Insight safer Diagnosis | 3

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Context: setting the sceneTerminology: Improving the diagnostic processAt the outset of the roundtable, some participants expressed concern with the term ‘diagnostic error,’ which is used commonly to refer to misdiagnosis, missed diagnosis and delayed diagnosis. They noted that:

• the term is used internationally but its appropriateness remains subject to considerable debate;

• there is pressure to put a label on each patient’s diagnosis at an early stage, even when it may not be appropriate to do so; and

• illness evolves, and data to make a diagnosis may not be apparent early on. In these cases, the issue may not be missed or delayed diagnosis, although it is a feature of the illness.

Participants suggested that a delayed or incorrect diagnosis does not necessarily create a clinical problem if the diagnostic delay or uncertainty is well managed.

In these circumstances, it is not appropriate to imply that an error has occurred. The most important issue is how the patient is managed as the diagnostic process unfolds. They noted that:

• achieving an accurate diagnosis may require prolonged and repeated processes of assessment and evaluation, during which a number of diagnoses may be considered and discarded; and

• as a patient’s symptoms and signs progress, or more information becomes available (e.g. from diagnostic tests), diagnostic options often narrow and it becomes easier to reach a firm and accurate diagnosis.

Roundtable participants suggested that the term ‘diagnostic error’ only describes a subset of diagnoses in which a delayed or incorrect diagnosis reflects a clear breach of the expected standard of care. There are many opportunities, however, to improve the quality of the diagnostic process and reduce associated risks even where there is no diagnostic error. Participants agreed that this should be the focus of the roundtable, rather than the narrower concept of diagnostic error. For this reason, the discussion at the roundtable addressed the broader issue of improving the diagnostic process.

The causes of misdiagnosis were discussed. Participants classified causes into four broad categories:

1. illness or presentation

2. Patient communication

3. Clinician factors

4. service system level

Published literature and research regarding misdiagnosis suggests that it occurs most frequently in the testing phase (failure to order, report, and follow up laboratory results), followed by clinician assessment errors (failure to consider and overweighing competing diagnosis), history taking, physical examination and referral or consultation errors and delays2, 3.

The rate of misdiagnosis depends on the medical specialty involved. In the specialties of pathology and radiology, some level of misdiagnosis has been estimated to occur in two to five percent of clinical cases, while in other specialties it occurs in 10 to 15 percent of cases. In post-mortem studies, evidence of misdiagnosis is present in over 40 percent of all clinical cases4, 5, 6.

System-related factors are estimated to contribute to misdiagnosis in two-thirds of cases and cognitive factors in three-quarters of cases7, 8:

• System-related factors include inadequate coordination of care, teamwork deficiencies, poor communication, insufficient training, weak policies and problems in the work environment.

• The most common cognitive problems involve faulty synthesis of clinical information. Premature closure, i.e. the failure to continue considering reasonable alternatives after an initial diagnosis is reached, is the single most common cause of misdiagnosis. Faulty context generation and misjudging the salience of findings are also important cognitive factors that contribute to misdiagnosis.

• The contribution of faulty or inadequate knowledge to misdiagnosis is debated across published studies. Some authors have found knowledge deficiencies to be an uncommon cause of misdiagnosis across studies9. Others have found that lack of knowledge is a significant contributor to misdiagnosis10.

• Diseases that may be subject to higher rates of misdiagnosis include infection, neoplasm, cardiovascular disease (including myocardial infarction, angina pectoris and cerebrovascular accident), pulmonary emboli, and adverse drug events11. In addition, trauma and orthopaedic conditions are clinical conditions commonly associated with failure to diagnose12, 13.


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There were varying views among participants about trends in risk associated with the diagnostic process in the Victorian healthcare system.

Some participants believe that improvements in technology and processes through the introduction of defined clinical systems in some clinical areas have reduced risk and considerably improved the quality of the diagnostic process. For example, the implementation of trauma and cardiology systems of care has been demonstrated to have had a major positive impact on diagnostic and treatment processes and outcomes. On the other hand, there is a view that demand and throughput pressures, combined with workforce changes, have led to increased risk.

It is important to note that diagnostic risks are not limited to the emergency department. Participants commented that diagnostic risks exist throughout the healthcare system and also in outpatient/consulting and inpatient settings. In the rural/regional setting, LAOS (limited adverse occurrence screening) is a useful clinical risk management tool used by clinicians to identify adverse events and make improvements to local systems for better clinical care.

It was agreed that the data currently available do not allow reliable identification of trends in diagnostic risks or adverse events associated with diagnostic processes. All roundtable participants agreed, however, that there is considerable potential to improve diagnostic processes in the Victorian health care system, thereby reducing patient and system-wide risks.

“Some of it still comes back to the primary doctor not taking a proper history and doing a proper examination at the outset.”A/Professor Ian McInnes, General Surgeon

Professor Stephen Stuckey, Director of Diagnostic Imaging and Head of MRI, Southern Health makes a point


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Discussion topicsRoundtable participants considered the following questions:

Topic 1: Which factors make the most significant impact on the quality of the diagnostic process?

Topic 2: What can/should be done to improve the diagnostic process?

Topic 3: How can the VMIA work with healthcare providers and other stakeholders to achieve sustainable change?

Topic 1: Which factors make the most significant impact on the quality of the diagnostic process?

Factors that impact on the quality of the diagnostic process were presented in the background paper for the roundtable (Table 1). The roundtable participants generally endorsed this table as reflective of the range of factors that impact on the diagnostic process in a working clinical setting.

Table 1: Factors that impact on the quality of the diagnostic process (modified from table provided by Professor Kelly)

Category Examples

1. illness or presentation level Atypical features or presentations of the illness, e.g. silent myocardial infarction

Rare clinical conditions

2. Patient communication level Failure to communicate all relevant clinical information, e.g. past history, medications, circumstances

Cognitive/communication problems

Doctor shopping

3. Clinician level Failure to collect enough clinical information

Failure to interpret clinical information correctly

Failure to investigate appropriately

Failure to interpret investigation results appropriately

Failure to consult with more senior/specialist clinician

Failure to communicate with patient re potential course of condition and triggers for further assessment/treatment

Failure to communicate with GP re potential diagnoses, etc

Failure to communicate with specialist teams

4. service system level High clinical work load pressure

Difficulty accessing senior clinician/specialist opinion

Limited access to investigations

Pressure to meet arbitrary ED discharge targets, e.g. four-hour target

Delays in reporting of investigations

Incorrect report of investigation results provided to clinician

Handover between shifts




Knowledge about current performanceThere was discussion about whether the VMIA’s data provide an accurate indication of the risk profile of the diagnostic process. It was noted that the VMIA only receives notification of incidents which have the potential to turn into claims, and therefore its data do not reflect the full range of risks and opportunities in the diagnostic process. It was also noted that the incidence of complaints in health services generally is increasing, although many do not transform into medico-legal claims and therefore remain largely invisible to the broader system. It was agreed that there are no readily available data that reliably reflect risks or improvement opportunities in the diagnostic process.

There were various views about whether performance in the diagnostic process is improving or deteriorating. It was suggested that while clinical improvement is occurring, the net effect of exponentially increasing workloads on the quality of the diagnostic process is unknown.

“As the workload continues to increase, expectations and demands on clinicians present a challenge for hospitals to continue to deliver high quality care.” Dr Heather Wellington, Facilitator

Increasing workload pressures on clinical staff have increased for many reasons, including staffing skill/mix models in hospitals, an increasing volume of patients being treated and a desire to meet hospital and ED access targets. These factors can lead to reduced quality of patient care and may be contributing to patient adverse events. Participants suggested that despite these factors that:

• systematisation of care has resulted in improved clinical outcomes in some areas;

• there is a higher clinical awareness of the risks inherent in the diagnostic process; and

• it is possible that overall performance is improving.

It was suggested that problems in the diagnostic process may manifest in different ways in a metropolitan setting as compared to a rural setting. Metropolitan settings are likely to have more senior staff available, but also face greater work pressures and higher workloads. Comparatively, rural settings tend to have a core staff that is more junior with senior support staff who are relatively unavailable, but a less intense workload.

The issue of when and where delayed/misdiagnosis is most likely to occur was discussed. VMIA’s and other data suggested that although the majority of misdiagnoses are attributed to emergency departments, they can have a cumulative aetiology and often cannot reasonably be attributed to a single clinical decision, department or process. It was noted, however, that for some conditions (e.g. ischaemic bowel), there is a very small diagnostic window if a patient is to be treated appropriately.

Roundtable participants discuss the causes and possible risk management strategies to help mitigate misdiagnosis


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1. Illness or presentation: Specific factors

Participants gave numerous examples of the types of illnesses and presentations which consistently give rise to concerns about the diagnostic process.

They agreed that there is considerable knowledge at the individual clinician level about which types of patients are likely to be at higher risk and that, while this information should be passed on to junior staff, this is not always being done effectively.

2. Patient communicationThe importance of high quality communication between clinicians and patients was discussed. Participants generally believe that the quality of communication with patients is deteriorating. Although the reasons for this are unclear, it was generally accepted that in part this was due to the pressure of high workloads and performance targets. It was suggested that this breakdown of communication may also reflect different generational attitudes.

It was noted that many patients are very knowledgeable about their disease and symptoms, but that often their knowledge is not recognised or relied upon. As a result, many patients feel they are not listened to.

“We’re doing a lot of work now around our complaints handling … in our review we’ve found that every single patient who complained about a doctor said they would not have done so if the doctor had spoken to them after the procedure. We had the sense from patients that if you talk to them and explain what will happen or what went wrong, they won’t complain.”Ms Lynette Ford, Melbourne Health

“There is a big gap in communication between clinicians and patients. I probably know my disease better than anyone else does because I live with it every day.” Ms Trudy Robson, consumer

Participants agreed that good communication may assist in averting action by a patient if an adverse event occurs, as patients may be more tolerant of mistakes if communication with their practitioner has been effective. Additionally, good communication throughout the diagnostic process can also be an effective preventive strategy, assisting to avoid an adverse event in the first place. For this reason, good communication is critically important.

The importance of healthcare providers demonstrating empathy towards patients was discussed. It was suggested that, “patients don’t care how much you know until they know how much you care”, and that some healthcare professionals give their patients the sense that they do not care. It was also suggested that the empathy demonstrated by the team is as important as the empathy demonstrated by individuals.

Participants agreed that the patient’s perspective does not always receive proper consideration. It was noted that from a patient perspective there may be:

• a requirement to ‘re-tell the story’ over and over again;

• little sense that ‘anyone knows the full picture’; and

• little systematic inquiry into their history or symptoms, or reliable processes for passing information from one provider to another.

It was agreed that patients expect to be dealt with honestly and that any uncertainty regarding their diagnosis will be conveyed to them.

Healthcare providers should not promulgate the expectation that a diagnosis will be made immediately for everyone.

Ultimately, communication between the patient and their practitioner regarding diagnostic uncertainty may reduce the possibility of a later perception of misdiagnosis and may result in earlier intervention if the patient is alerted to symptoms/signs that should prompt re-assessment.

The concept of patient rights and responsibilities was also discussed, with agreement that patients have a right to be encouraged and given sufficient time and attention to put forward all relevant information, and also a responsibility to inform the healthcare professional to the best of their ability.

The concept of the patient as an important member of the patient safety team was discussed. It was noted, however, that many patients are disempowered or unable to engage in the diagnostic process in this way because of language, social or medical circumstances.

The difficulty experienced by healthcare providers in determining which information offered by patients was helpful in making a diagnosis and which information was not relevant to the diagnosis, was also noted.




3. Clinician issuesThe quality of history-taking, examination and documentation were all noted as areas of concern. It was agreed that there are deficiencies in collection and synthesis of information which is necessary to achieve an appropriate diagnosis. Both recognition and synthesis of information can be deficient.

It was agreed that effective communication between clinicians makes a critical contribution to the quality of the diagnostic process. Failure of communication within and between clinical teams is thought to be an important cause of delays and errors.

Participants noted that work and staffing pressures in health services are impairing such communication, as is the physical design of some facilities. It was suggested that the quality of interactions between emergency, radiological and intensive care staff has a particularly important influence on the quality of the diagnostic process. Ensuring sufficient clinician time to enable inter-disciplinary discussion is essential.

Particular concern was expressed about junior staff failing to seek advice or support from senior staff when clinically necessary. It was agreed that there are underlying system issues which make it difficult for junior staff to seek advice in many circumstances. Night time is a particular problem, as junior clinicians may be reluctant to disturb senior clinicians who are asleep while on call. It was suggested that there is a “significant amount of grumpiness going on”, and that this can create a barrier to junior staff seeking advice from senior colleagues.

“Mistakes can happen everywhere, not just in the ED. You can be the sickest person in the hospital seen by the most junior doctor.”Dr Marcus Kennedy, Ambulance Victoria

Participants suggested that the discipline associated with collating appropriate information when preparing to present a case to a senior colleague is an important quality mechanism. Failure to consult with senior staff often means that these processes are avoided, leading to increased risk in the diagnostic process.

There was robust discussion about the role of checklists and guidelines which specify physiological criteria that should trigger more senior intervention in a patient’s care. The risk of over-reliance on such guidelines, which can hinder independent analysis about a patient’s condition, was contrasted with the benefit of more systematically identifying patients at risk during the diagnostic process. The specific risks at points of transition of care were noted.

The critical importance of the composition of the interdisciplinary team and the interdependence of medical and nursing care was also noted. The presence of senior, skilled and high performing

nurses in clinical teams is considered critical. Similar to junior doctors, the same situation exists with inexperienced nurses, and agency nurses who may be unfamiliar with a particular department, speciality or clinical team, failing to alert or escalate to medical staff a patient’s changing clinical condition.

Constraints stemming from privacy legislation were noted as a particular barrier to inter-organisational clinical communication.

“There are some issues, like this, that need a pathway. We need more consistent guidelines around commonly missed conditions.”Professor Stephen Stuckey, Southern Health

4. Service system issues

Leadership and managementIt was agreed that departmental leadership and management are critically important in a number of areas, including establishing an appropriate culture, managing resources efficiently, and defining expectations of quality of care and peer review.

Lack of consistent systems of careParticipants suggested that the devolved governance which characterises the Victorian public healthcare system is an impediment to the creation of ‘whole-of-system’ responses to quality problems. Health services sometimes behave as ‘competitive businesses.’ There is substantial support for more integrated ‘whole-of-system’ approaches to quality in the diagnostic process. The clinical networks established by the Department of Health offer a potential framework for this work, but infrastructure and processes are required to support it.

Workload and other work pressuresParticipants described highly stressful working environments characterised by interruptions, distractions, fatigue, shift work and cognitive overload. Demand for services was described as having

“no boundaries”. Participants described “constant distractions” caused by administrators seeking to ensure access targets are met. Data entry requirements are increasing. It was suggested that “we cannot work faster or more cleverly.”

“Demand is increasingly unbounded.”Dr Helen Stergiou, The Alfred


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triage processesThere is concern about the effectiveness of the triage process in emergency departments. The questions were asked: “Who makes the decision about who is sick and who is not? Who recognises the severity of the patient’s presentation?” It was agreed that there are deficiencies in recognition of clinical risk in presenting patients.

Management of investigations and other clinical informationVMIA roundtable participants agreed that there is a large practice gap relating to follow up of investigations. At times, clinicians are unaware that an investigation has been ordered by a colleague. Handover of results (particularly in the outpatient setting) is often not done well. These issues are challenging to manage because care has become more fragmented with changing patterns of work and rostering of medical staff. Some health services have implemented information technology-based solutions to assist with the management of information relating to investigations, but there is no standardised approach across the system.

“The consistent issue is lack of senior clinician involvement early enough, in other words, a lack of early escalation. Talk to your boss. Speak to someone with experience. Junior doctors just don’t escalate early enough.”Dr Helen Stergiou, The Alfred

The participants highlighted that there are particular risks around the follow up of abnormal pathology. This was identified incidentally during an investigation ordered for another purpose.

While a universal healthcare record will assist, this issue needs to be systematically addressed without reliance on the electronic medical record alone. The option of patients having greater personal access to their medical histories was raised and the development of the national personally controlled electronic health record was noted, although that record is not expected to be complete or widely available within a short time frame. It was also noted that patients generally expect ‘the system’ to manage their information and not all patients see it as their personal responsibility to ensure that the system is well informed about their condition.

Workforce availability and useIt was agreed that healthy cultures and systems require staffing at consistently safe levels, but that this is not always achieved. There is particular concern about junior doctors and international medical graduates working in rural settings in which there are relatively fewer senior support staff. It was suggested that nurses in these settings are often taking high levels of responsibility. The workload is often lower than in metropolitan settings, but there are concerns about the overall competency of clinical teams. Junior staff in metropolitan settings may also be unsupervised overnight.

The availability of specialist advice in relation to seriously ill patients through organisations such as Adult Retrieval Victoria and the poisons advice line, was noted, but it was also noted that these systems are fragmented and only apply in particular circumstances. Extension of specialist, centralised systems is one possibility to improve performance across the State.

The approaching ‘surge’ of interns and associated supervision requirements resulting from increased intakes in universities requiring adequate supervision is a cause for concern.

Roundtable participants – From left to right: Professor Anne-Maree Kelly, Ms Trudy Robson, Ms Filomena Ciavarella




Topic 2: What can/should be done to improve the diagnostic process?

A variety of methods for reducing misdiagnosis have been proposed in published literature around the subject and were discussed at the roundtable. These include but are not limited to14 15:

• strategies to improve communication between providers, and between provider and patient;

• strategies for supervision, including second opinions, clinical audit and peer review strategies;

• voluntary reporting of errors (including misdiagnosis) and sharing of learning from errors for system re-design;

• the use of clinical decision support systems that assist the health professional with decision-making tasks; and

• performance appraisal and performance management, to ensure standards of care are of high quality, including credentialling and scope of practice processes that ensure the provider who administers care is appropriately qualified to do so.

Systems solutions generally address one or more of the following16:

• Communication and coordination of care;

• Teamwork/supervision;

• Technology/equipment - related issues;

• Organisational features;

• Safety culture;

• Policies, procedures;

• Leadership, management or personnel;

• Resources/expertise; and

• Training.

Cognitive solutions can focus on17 :

• Increasing medical knowledge and expertise;

• Improving clinical reasoning; and/or

• Providing triggers for when to get help.

Roundtable participants identified numerous actions which could assist in improving management of the diagnostic process. They noted the potential costs of introducing new systems, but also the existing cost of poor quality care which is not quantified but is likely to be substantial.

Audit and benchmarkingImproved audit and benchmarking was proposed as the most effective means of determining the scope and aetiologies of problems with the diagnostic process and the interventions which are likely to be most effective in addressing them.

Systematic follow up of defined categories of patients was identified as a potentially useful mechanism. Time for collecting information and reflecting on it would be necessary to implement such a system.

“It’s all very well to think about timing and have the opportunity to reflect, but in the ED we have to make a decision now, we have to do something now.”Dr Helen Stergiou, The Alfred

It was strongly agreed that there should be more formal, structured audit processes in emergency departments. Participants described a lack of feedback about patient outcomes, so misdiagnosis or opportunities for improvement in the diagnostic process are not always recognised. There was strong support for more systematic measurement of quality, as well as activity, in relation to the care of emergency department patients. Participants also noted that there is a gap in knowledge about which interventions work to improve the diagnostic process and which do not.

Although patient numbers in particular categories are thought to be relatively low in individual organisations, thereby diminishing the statistical power of analysis in relation to specific conditions, participants said there is sufficient data potentially accessible across the system to enable a much more thorough understanding of current problems. They noted that barriers to sharing information between organisations need to be overcome to enable these data to be used effectively.

Participants agreed that a multidimensional approach to audit is required, with prospective data collection on identified patient groups a key audit strategy. Review of the care of cohorts of people who experience poor outcomes should also be conducted. It was agreed that monitoring of complaints is a useful but


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not sufficient strategy to understand quality improvement opportunities in the diagnostic process, and that it does not adequately replace systematic clinical audit.

It was suggested that health service quality resources are being preferentially directed, via national policy, into incident management systems and measurement of a narrow range of adverse events including infections, falls and pressure ulcers. Incident management systems were generally viewed by participants as unhelpful in relation to the issues discussed at the roundtable. They suggested that there is not a definable incident or an adverse outcome is recognised at another health service, rather than the health service in which the diagnostic process mainly occurred.

It was agreed that there are few resources available for targeted audit designed to investigate defined areas of clinical concern. Where this occurs, it tends to be limited to medical practitioners rather than being team-based. Participants suggested that the overall lack of resources and the way resources are currently applied are viewed as serious deficiencies which are likely to be exacerbated by the new healthcare standards being implemented nationally. On the other hand, it was suggested that there is considerable national interest in measuring quality of ED care in association with the introduction of new national hospital access targets, which may be associated with new resources which could be applied more effectively.

Participants noted the criticality of data being applied to develop solutions, rather than simply to identify the source of problems.

Medical staffing and supportGenerally, there was a view that current senior medical staffing models do not accord with healthcare demands. There was very strong support for the concept of reviewing medical staff structures.

It was suggested that current medical staffing models were developed in an era when medical staffing was more continuous and demands were considerably less. Some participants believe that the current models of medical staffing are not serving the system well. It was suggested that there are more resources in the system now than ever before, but they are not being allocated or used well.

There is considerable interest in the concept of sharing senior resources between organisations overnight, so that junior staff have direct access to a senior person who is on duty for that purpose.

The role of telemedicine in radiology, which enables provision of ‘on duty’ video-based advice by senior staff on a continuous 24-hour basis, was discussed and it was suggested that a centralised, system which provided junior staff across the State with immediate access to specialist advice on a continuous basis could be considered.

Dr Helen Stergiou, Deputy Director, The Emergency and Trauma Centre, The Alfred listens to Dr Marcus Kennedy, Director, Adult Retrieval, Ambulance Victoria




“It’s about how the team backs each other up.”Professor Peter Cameron, The Alfred

“X-ray, Emergency and ICU should always meet together … they are in a marriage.”Dr Anthony Felber, Epworth Health

It was agreed that further work is required to support senior staff to respond appropriately to junior staff when they are contacted for advice and that is an ongoing issue of performance management. Providing coaching or monitoring on good communication techniques and values could be considered. Generally, participants agreed that the performance is improving, but there is a significant leadership and management need in this area. Participants noted that the problem can be very difficult to manage in smaller facilities when there is no alternative workforce available.

The possibility of using information technology to assist junior staff to see senior staff when they are discussing patient care was raised. It was suggested that if people could see each other, they would be less likely to respond inappropriately to requests for assistance.

It was suggested that processes to appropriately integrate subspecialists into the diagnostic process also need to be developed.

It was agreed that there needs to be a more transparent and overt description of the medical culture which is required in high performing hospitals.

Systematisation of careOn balance, roundtable participants agreed that guidelines and checklists have an important role to play in encouraging appropriate communication within clinical teams. It was strongly suggested that consistent processes should be developed across the Victorian healthcare system, rather than numerous processes being developed locally. It was noted that this would require some level of coordination, in the context of Victoria’s system of distributed governance.

It was suggested that the information technology capability exists for information to be extracted from various hospital records for the purposes of risk profiling at the time of presentation. There was support for the suggestion that ‘red flags’ could be systematically generated, based on known clinical information, to identify patients at particular risk during the diagnostic process. Those patients would then be subject to more intensive management and follow up including, for example, mandatory senior clinician review, targeted clinical support systems to assist clinicians to manage them effectively or systematic post-discharge follow up.

“A lot of it comes back to patient expectation … We have to make it OK for them to speak up by targeting both clinicians and patients.”Dr Marcus Kennedy, Ambulance Victoria

The concept of mandatory ‘consultant sign off’ for patients with particular characteristics was discussed. It was noted that it has been introduced in the United Kingdom for some categories of patients but that the outcomes are unknown. The concept is based on putting supports in place around young clinicians to assist them to apply their knowledge effectively. There was a view that it would assist with information synthesis and there was strong support for implementing and evaluating this concept, while recognising that adequate resourcing would be required to pilot this.

TrainingTraining in misdiagnosis was proposed as a means of enabling clinicians to understand and modify how they think. It was noted that clinicians usually find it very helpful to understand their decision-making processes and often can modify them as a result of such training.

Training in conditions in which there is a high risk of misdiagnosis was also proposed. It was suggested that the concept of ‘red flags’ (discussed above) would also be useful to support the development of an educational program.

There was support for a specific training program in receptiveness to requests for advice. The issue, which affects clinicians across all disciplines, is considered to be highly significant and deserving of a specific body of work.


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Information managementParticipants agreed that systems for following up investigations are considered to be extremely important. It was agreed that the process of requesting an investigation should include systems for identifying how the result is to be managed, noting that the result must always come back to a ‘safe place’ where the ordering clinician has a fundamental professional obligation to ensure appropriate follow up occurs.

“We’re doing a lot of auditing but there is a difference in the buy in from different disciplines. An audit of doctors is very different from a general systems audit.”Ms Lynette Ford, Melbourne Health

VMIA roundtable participants believe there is a need for common follow up functions and processes across organisations, although it was agreed that the information systems that support them need not be common. It was also agreed that there is useful work to be done in describing the fundamental standards that should apply to the ordering, management and follow up of investigations and ensuring they are reliably implemented, drawing on the substantial work that has already been done in this area within some organisations.

Participants also suggested that there is potential to further develop clinical decision aids such as ‘pop up boxes’ that ‘push’ communication about abnormal pathology results, and that the development of automated systems could likewise help with patient triage and handover.

It was agreed that clinicians should have technologically-enabled access to all medical imaging films, electrocardiographs, and other information relevant to the patients they are being asked to advise on. This is ‘patchy’ at the moment, with some barriers caused by lack of infrastructure and others caused by incompatible systems.

“A patient needs to be aware that they have communication responsibilities as well as rights. An incomplete or erroneous information trail can lead to a terrible outcome.”Professor Anne Maree Kelly, Western Health

Better communication with patients could result in improved follow up care after discharge from hospital. Patients need to be empowered to understand their healthcare needs and be engaged in their medical care.

It was noted that privacy legislation establishes information-sharing constraints and that there would be benefit in defining the specific barriers that are created and determining whether there are practical responses that could be implemented to manage them.

Follow up of high risk patientsIt was noted that some international and local organisations have implemented telephone follow up of high risk groups, where the results are collated and the patient is contacted directly to ascertain their current status. The task is usually undertaken by a senior nurse. The system is resource-dependent but participants considered it likely to be effective.

“Our focus should be on the front end, i.e. managing the diagnostic process, not just at the end of the process.”Dr Alastair Mah, Melbourne Health

Ms Vanessa Lane, Manager Quality, Safety and Patient Experience, Department of Health




Topic 3: How can the VMIA work with healthcare providers and other stakeholders to achieve sustainable change?

Recommended project categoriesVMIA roundtable participants considered the categories of projects which would provide the best opportunity for the VMIA, in partnership with providers, to assist to reduce risk associated with the diagnostic process. It was noted that resources will be best utilised by highlighting or piloting best practice approaches to reform.

Five categories of projects were proposed:

Potential Project 1: Audit leading to knowledge and improved practice.Projects in this category would have the objective of:

• establishing a common system across the State for longitudinal, interdisciplinary auditing of the diagnostic process, drawing on existing audit tools and focussing on their practical implementation across organisations;

• providing benchmarked data about the areas in which diagnostic risk is most problematic; and

• identifying appropriate interventions which are likely to address the underlying causes of risk and error, including:

• strategies to ‘red flag’ high risk patients (e.g. abdominal pain in the elderly);

• areas in which guidelines would be most usefully developed; and

• areas in which training would be most productively progressed.

These projects would need to be highly collaborative and it was suggested that the establishment of the Victorian Emergency Department Collaborative may be an appropriate vehicle to pilot this work.

Potential Project 2: innovative approaches to supporting junior staff.Projects in this category would address the myriad of issues that impair access by junior staff to effective senior advice, including:

• different ways of structuring and providing medical services;

• improving access to senior advice utilising information technology solutions (e.g. videoconferencing); and

• training junior and senior staff in effective communication.

Potential Project 3: systems for following up investigations.Participants supported a ‘stock take’ of what is already in place in Victorian health services for managing the follow up of results of investigations.

Potential Project 4: Consumer- directed strategies.Projects in this category could address:

• communication with consumers; and/or

• systems for following up high risk patients.

Potential Project 5: information technology solutions to managing risk in the diagnostic process.Projects in this category could address information technology approaches to risk identification, clinical decision-making aids, and/or follow up of results.

The findings of this Roundtable were consulted to the wider client base at an Executive Healthcare Breakfast Forum.

how to get involvedThe VMIA’s Risk Management Partnership Program supports risk management projects undertaken by our clients that are designed to reduce the State’s total cost of risk. We provide financial and project management assistance to projects which have potential to be implemented across Victoria. For further information or to see if your project qualifies, email [email protected] or visit www.vmia.vic.gov.au/riskpartnershipprogram


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DisclaimerThe information provided in this document is intended for general use only. It is not a definitive guide to the law, does not constitute formal advice, and does not take into consideration the particular circumstances and needs of your organisation. Every effort has been made to ensure the accuracy and completeness of this document at the date of publication. The VMIA cannot be held responsible and extends no warranties as to the suitability of the information in this document for any particular purpose and for actions taken by third parties. This document is protected by VMIA copyright.

www.vmia.vic.gov.au

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14 Decision support systems. Open Clinical. 24 July 2006. www.openclinical.org/dss.html viewed October 2011.

15 Briggs G, ‘The role of specialist neuroradiology second opinion reporting: is there added value?’, Clinical Radiology vol. 63, 2008, pp. 791-795.

16 Singh H, ‘Interventions to Reduce Diagnostic Errors in Ambulatory Care’, in AHRQ 2010 Annual Conference, November 2010.

17 ibid


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Documents

Risk Insight 14 - Safer Diagnosis