November 12, 2012

Diagnostic Errors in Medicine

William Strull, MDMedical DirectorQuality and Patient SafetyThe Permanente Federation, LLC

Prepared by: Bettygene Egan, MBA

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Kaiser Permanente Regions

Coded Closed Claims

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Claims Distributions Payout Distributions

DiagnosisDiagnosis

High-Level Categories

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Cognition

Visual diagnosis

Closing the loop/Follow-up

Staff Engagement and Learning

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Communication down to the front line level

Diagnostic Reliability and Improvement Initiative Team and Committees (DRII)

Risk Managers Operations Team

Sentinel Event Risk Care Integration Team

Analyze, Share, Prevent, Inter-REgionally,

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Specimen Handling & Tracking

Anatomical Specimen Handling

Inter-Regional Specimen Tracking

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Specimen Handling

Anatomical Pathology Specimen Handling Project

Colorado Region

Background Strategic Alignment

Strategic KP Imperatives

• Transform Care Delivery

• Solving for Affordability

• Lack of a uniform specimen tracking mechanism throughout Kaiser Permanente has lead to lost or misplaced specimens during transit or while being processed at hospital or regional laboratories.

• Existing Specimen Tracking capabilities do not support all specimen tracking needs for Kaiser Permanente’s multi-site intra-regional laboratories.

• Some of the identified specimen tracking pain points during specimen transport includes: specimens lost, misplaced, misrouted, relabeled and stored at the incorrect temperature resulting in unusable specimens . Then they must be recollected when possible resulting in missed or delayed diagnosis, and even litigation risks when high value specimens are lost or mishandled.

• The consequence of a loss depends on the type of specimen, varying from the irreparable impact of a lost diagnostic specimen that can’t be recollected to the inconvenience a member experiences being recalled for a repeat blood collection.

• Ultimately, these lost specimens results in decreased member and provider satisfaction, increased costs due to repeated procedures or even worse, litigation.

CD Bio National Strategy

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Benefits Realization• Continuous Improvement

• Productivity Gains

• Compliance Requirements

• Cost of Doing Business

• Member Satisfaction

Identify and Manage

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Outpatient Safety Nets that proactively identify and manage patients with an outpatient safety risks

Categories of Gaps

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Necessary Follow-up Care Tracking/follow-up of abnormal results

Medication Management Appropriate monitoring for long-term medications

Diagnosis Detection Identify potentially undiagnosed cases

Potentially Harmful Interactions Pharmacist recommends alternative drug therapy

Patient Safety Measurement Portfolio

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• % of breast cancer diagnosed at stage 1 or 2

• % of cervical cancer diagnosed at stage 1 or 2

• % of colorectal cancer diagnosed at stage 1 or 2

• Testing for HIV among HIV uninfected members diagnosed with sexually transmitted infection

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The After Visit Summary• Improves patient follow through with the completion of diagnostic

tests• Engages the patient as “partner”• Is the #1 member satisfier

Overdue Results Notification• Provides a safety net to ensure that tests are completed

“Tickler” Reminder Messaging• Allows clinicians to send themselves a reminder to make sure an

urgent or important diagnostic test, referral or “hand off” has been completed

In Basket Monitoring• Ensures that all in basket messages, with abnormal results, have

been addressed in a timely manner

KP HealthConnect

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Engagement

Patient Family Centered Care

SMART Partners

Diagnosis and Engagement

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Diagnosis and Engagement

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Questions

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