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29 Exploring the diagnostic process by analyzing adverse events and malpractice claims – how can data be relevant for preventing overdiagnosis as well as underdiagnosis?
  1. Charlotte Frendved
  1. Danish Society for Patient Safety, Copenhagen, Denmark


Objectives Internationally there appears to be two distinct themes emerging in relation to diagnosis.

One, initiated by the Improving Diagnosis in Health Care-report in 2015 focuses on avoiding underdiagnosis (missed/delayed/wrong diagnosis) by improving diagnostic safety. .

The other theme centers on the prevention of over-testing and overdiagnosis, to protect patients from unnecessary (potentially harmful) treatment, and to save resources in an overburdened health care system.

The aims of the presentation are to discuss:

  • how this knowledge can be relevant for preventing overdiagnosis as well as underdiagnosis,

  • and how to create synergy between these two efforts: Preventing overdiagnosis and preventing underdiagnosis (missed/delayed/wrong diagnosis).

Method To improve diagnostic safety, the Danish Society for Patient Safety together with partners have carried out analysis of malpractice claims from the Danish Patient Compensation, and another analysis of adverse events registered in the Danish Patient Safety Database. This research has explored and exposed weak steps in the diagnostic process that could be critical for overdiagnosis as well as for underdiagnosis.

213 malpractice claim cases and 300 adverse events with relation to the diagnostic process was analysed with tools, making it possible to identify which phase in the diagnostic process was affected.

During the process of auditing and analysing cases from 2019 to 2023, we have held several workshops, encouraging Patients representatives and other stakeholders to discuss the subject of diagnostic safety and generate ideas for solutions.

Results In the analysis of the malpractice claims (all cases recognized as diagnostic errors) reviewers found, that 80% of cases was related to the ‘initial diagnostic assessment’, 27% of cases to ‘testing and results processing’, and 33% of cases to ‘follow up and coordination’. Analysis of adverse events (including events regardless of severity) gave a different picture: about half of the events were related to ‘testing and result processing’. During the analysis we found several cases of erroneous diagnoses leading to unnecessary and potentially harmful treatment. Also relevant for the discussion, is the frequent phenomenon of random/coincidental abnormalities. For instance, while taking an x-ray of an injured shoulder, you accidentally discover at spot on the lung. Ideas for solutions and interventions generated at the workshops include ‘patient involvement’, ‘psychological safety’ and ‘feedback’, all of which could be relevant in relation to overdiagnosis.

Conclusions Preventing overdiagnosis and avoiding underdiagnosis (missed/delayed/wrong diagnosis). It seems that these two efforts are sometimes in opposition. We would like to start a conversation focused on how to create synergy between these two efforts. We believe that research on the causes and patterns of diagnostic errors, and research highlighting weaknesses in the diagnostic process, potentially contribute useful information for preventing overdiagnosis. Some of the interventions designed to reduce diagnostic errors (more testing, diagnostic bundles etc.) might lead to overdiagnosis. Other interventions like feedback might be beneficial in both contexts. Feedback to clinicians not only regarding diagnostic accuracy but also regarding the assessments and choices made during the diagnostic process (e.g did I order the right tests? Was this scan necessary? Etc.) What interventions would potentially improve diagnostic safety while at the same time preventing overdiagnosis, and how can we include both efforts in the search for ‘diagnostic excellence’

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