Monitoring and Safety

Morbidity and Mortality reviews

Morbidity and Mortality (M & M) meetings are an ideal place to evaluate diagnostic error cases in a multidisciplinary environment that includes all the team members involved in the care of that patient. The following guidelines are useful to consider when discussing diagnostic error in M & M meetings:

  1. Discuss as early as possible after the error has occurred so that it is fresh in all team members minds
  2. Use the Cognitive Autopsy Guidelines as a reference to encourage reflective discussion about events leading up to the error
  3. Focus on identifying issues related to the processes or systems of care that lead to the error and not on the individuals.
  4. Document the discussion, outcomes and key learnings

Evaluating clinical practice and improvement

Clinical audit that compares differential diagnoses and initial diagnosis with discharge diagnosis is an ideal way to identify types and trends in diagnostic error that is not detected by other means. These are frequently the cases where the impact to the patient was low, however will often be associated with extended hospital stay and increased investigations while the correct diagnosis is identified.

Very rarely do we go back and review the records of a patient once they have been transferred to another team or discharged from our care. Looking back at these cases provides a unique insight into the accuracy of our own decision making and is an excellent teaching tool for junior clinicians.

Sample audit tools have been developed to monitor and evaluate diagnostic error practices.

Clinical Incident Management and Reporting

All diagnostic errors and near misses are classified as an adverse event and as such should be reported in the Incident Information Management System (IIMS) in the Principal Incident Type - Clinical Management, sub-category diagnosis - missed or diagnosis - delayed.

IIMS NSW Health employees - Submit diagnostic error related incidents

Patient Safety Data and Information

NSW Health data on diagnostic error is collated from the Incident Information Management System. The Diagnostic error team reviews this data regularly, identifying risks and opportunities to improve care at the system level.

Information on clinical incident reporting and management in NSW can be found on CEC's Incident Management pages.