Day One - System Focus | Working Together to Improve Diagnosis Virtual Conference
This conference, a three half-day virtual conference, will highlight the alarming impact diagnostic error has on patients or residents, care teams and organizations. It will energize teams to identify opportunities for reducing diagnostic error in their own organization by identifying best practices and successes from leading experts. Additionally, it will highlight the importance of communication when a harm event does occur. Participants will have the opportunity to join a new collaborative dedicated to improving the diagnostic process; a year-long group whose focus will be on reduction in patient harm and the subsequent financial burdens, while supporting the implementation of new strategies and shared experiences.
C-Suite, physicians, administrators, patient safety/risk personnel, system engineers, quality leaders and practice leaders from hospitals, clinics, senior living and long-term care organizations
8:30 - 9:45 AM | KEYNOTE: Defining the Landscape and Setting the Agenda for Diagnostic Errors: What will it Take to Achieve Diagnostic Excellence
David Newman-Toker, MD, PhD, Director, Armstrong Institute Center for Diagnostic Excellence, Johns Hopkins Medicine, Baltimore, MD
Diagnostic errors are almost certainly the most common, most costly and most catastrophic of medical errors. Despite this, they were largely ignored for the first two decades of the patient safety movement era. Over the past five years since the publication of the National Academy of Medicine report on Improving Diagnosis in Healthcare, this has finally begun to change. In this session, the speaker will review the scope of the problem, the complexity of causes and the need for multi-faceted solutions at provider, organizational and system levels.
- Summarize the public health burden and financial impact of diagnostic error and misdiagnosis-related harms.
- List common causes and prioritize targets for diagnostic error reduction and quality-improvement initiatives.
- Discuss solutions at provider, organizational and system levels that can contribute to diagnostic excellence.
10:00 - 11:00 AM | Exploring Solutions to Address Diagnostic Error
Dana Siegal, RN, CPHRM, CPPS, Director, Patient Safety Services, CRICO Strategies, Boston, MA
Diagnostic errors are typically driven by two primary causes: cognitive failures and system failures. In this session, Dana Siegal will share national Medical Professional Liability (MPL) claims data illustrating the prevalence of these challenges in diagnostic error cases, and present solutions to both sources of error, including raising awareness regarding cognitive biases and highlighting decision support tools to aid in this process. She will also present systems-based solutions for closing loops in referral and test result management processes.
- Identify primary cognitive- and systems-based drivers of diagnostic error.
- Discuss the burden of those drivers on providers and care teams through the lens of medical professional liability claims.
- Identify specific solutions to address cognitive- and system-based drivers of diagnostic error.
11:15 AM - 12:00 PM | The Emotional and Organizational Cost of Harm
Julia Prentice, PhD, Research Director, Betsy Lehman Center for Patient Safety, Boston, MA
Medical error can have significant emotional, financial, physical and socio-behavioral impacts, including reduced healthcare trust and avoidance. The Massachusetts Betsy Lehman Center for Patient Safety fielded a statewide survey to increase their understanding of how patients and families experience medical error. This session will review the data examining the long-term impact of medical error, discuss the relationship between open communication and long-term impacts and identify current tools for communication and resolution best practices.
- Identify long-term risks of medical error including emotional harm and healthcare aversion.
- Assess the impact of transparent communication about the medical error on long-term risks.
- Identify available communication and disclosure tools.
Day One Speakers
David Newman-Toker, MD, PhD
David E. Newman-Toker is a Professor of Neurology, Ophthalmology and Otolaryngology at the Johns Hopkins University School of Medicine. He also holds joint appointments in Emergency Medicine and Health Sciences Informatics at the School of Medicine, as well as in Epidemiology and Health Policy and Management at the Johns Hopkins Bloomberg School of Public Health. Dr. Newman-Toker also serves as the President of the Society to Improve Diagnosis in Medicine. Dr. Newman-Toker’s academic mission is to eliminate harms from diagnostic errors and maximize the accuracy and efficiency of diagnostic testing in clinical practice. He is as a core faculty member of the Armstrong Institute for Patient Safety and Quality, where he serves as Director of the Johns Hopkins Armstrong Institute Center for Diagnostic Excellence, focused on enhancing diagnostic safety, quality and value. Dr. Newman-Toker’s research focuses on preventing missed strokes in the emergency department and primary care, especially among patients presenting with acute, severe vertigo or dizziness.
Julia Prentice, PhD
Julia Prentice leads the research portfolio at the Betsy Lehman Center. Her projects focus on measuring the prevalence of adverse events, understanding the public perception regarding the long-term impacts of medical error and the health system response, and evaluating the effectiveness of key quality improvement initiatives. Her previous work in the Department of Veterans Affairs (VA) focused on advancing the ability of healthcare systems to enact evidence-based policy and clinical practice. She was the first to find a consistent relationship between longer appointment wait times for VA healthcare services and poorer patient-level satisfaction and health outcomes. In 2013, this work provided the evidence base for a change in access metrics used by the VA and helped to address the access crisis in 2014. Prentice received her doctorate in public health from UCLA, where she also earned her master’s degree in public health. As an undergraduate she studied biology and sociology at Grinnell College.
Dana Siegal, RN, CPHRM, CPPS
Dana Siegal is the director of patient safety for CRICO Strategies, where she provides analytical and educational services to leading academic medical centers, community hospitals and physician practices on the issues of medical liability and patient safety. She evaluates the risk profiles of healthcare organizations throughout the country, assessing where current vulnerabilities exist and making recommendations for prioritizing action plans. Additionally, she provides detailed analysis of medical malpractice claims, with a specific focus on Diagnostic, OB, EHR and Emergency Medicine. Siegal has 30 years’ experience in healthcare quality and risk management, ranging from front line clinical care as an emergency room nurse, to front line risk management where she was involved in all aspects of incident reporting, sentinel event management, root cause analysis and credentialing. She has worked closely with clinicians and administrators in development and implementation of incident reporting systems and has extensive experience in the analysis of hospital and provider performance data and development of patient safety initiatives in a variety of clinical practice settings. Siegal is a Registered Nurse and is a Certified Professional in Healthcare Risk Management and a Certified Professional in Patient Safety.
Nursing Contact hours and Certificate of Attendance are not available for the on-demand course.