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Joint Commission issues 10 new practices for protecting patients against diagnostic errors

by John R. Fischer, Senior Reporter | November 03, 2022
Risk Management
The Joint Commission has published 10 new practices for reducing diagnostic errors.
The Joint Commission has published ten new recommendations for reducing diagnostic errors and keeping patients safe.

Studying missed, delayed or wrong diagnoses and other errors, researchers at the nonprofit came up with the list of potential practices from literature reviews, national and international organization reports, interviews with quality and safety leaders, and input from other experts.

Their study is called Developing the Safer Dx Checklist of Ten Safety Recommendations for Healthcare Organizations to Address Diagnostic Errors.

Consulting a Delphi expert panel of 28 individuals, followed by an online panel of 10 experts, the group whittled the list down to the following ten:

  • Create organizational leadership that builds a “board-to-bedside” accountability framework
  • Establish a just culture and psychologically safe environment for diagnostic safety
  • Create feedback loops to increase information flow
  • Implement multidisciplinary perspectives, including cognitive science and human factors, when analyzing diagnostic safety events
  • Incorporate patient and family feedback to identify and understand safety concerns
  • Let patients review their health records; help them understand and act upon their diagnostic information
  • Prioritize equity in diagnostic safety efforts by segmenting data to understand root causes and implement strategies to reduce equity gaps
  • Standardize systems and processes for direct, collaborative interactions between treating clinical teams and diagnostic specialties
  • Standardize systems and processes to reliably communicate diagnostic information between care providers, patients, and families during handoffs and transitions
  • Standardize systems and processes to close communication loops and follow up on abnormal test results and referrals

The Delphi panel identified 71 practices from the list, with 65% of participants agreeing on 28 of them. The multidisciplinary online panel cut this down to ten.

Prioritization was based around impacts to patient safety and whether or not providers could feasibly implement each recommendation within one to three years. Each suggestion is listed with implementation guidance and cognitive walkthroughs of the checklist for a face-validity check with providers.

“We were particularly delighted to see a call to focus on diagnostic equity, transitions of care and the critical role of patients and families on the diagnostic team and in the diagnostic learning system,” wrote the authors in an accompanying editorial.

Dr. Hardeep Singh, a professor of medicine at Michael E. DeBakey VA Medical Center and Baylor College of Medicine in Houston, led the study.

The findings of the study were published in the November 2022 issue of The Joint Commission Journal on Quality and Patient Safety.

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