Diagnosis is an essential part of the nurse practitioner (NP) role. An accurate diagnosis serves as the basis for treatment and achieving optimal patient outcomes. Unfortunately, making a diagnosis can be a complicated process that can lead to errors. An inaccurate or missed diagnosis can result in an NP being named in a lawsuit, which can have professional (loss of job) and personal (loss of income) consequences. In fact, NSO and CNA’s 2022 report, Nurse Practitioner Professional Liability Exposure Claim Report: 5th Edition, notes that diagnosis-related malpractice claims topped the list of reasons for allegations against NPs at 37.1 percent of claims in the report dataset. But by understanding potential sources of error during the diagnostic process, NPs can help ensure patients receive optimal care and reduce their risk of legal liability.
A real-world issue
The National Academy of Medicine’s (formerly the Institute of Medicine) 2015 report, “Improving Diagnosis in Health Care,” cites several statistics related to the prevalence of diagnostic errors, including that about 5 percent of adults who seek outpatient care each year experience a diagnostic error, with these errors accounting for about 6 to 17 percent of hospital adverse events. In addition, postmortem examination research indicates that diagnostic errors contribute to about 10 percent of patient deaths. Perhaps most sobering is that the report committee concluded that most people will “experience at least one diagnostic error in their lifetime, sometimes with devastating consequences.”
A 2018 report from the Pennsylvania Patient Safety Authority (PSA) found that 11.4 percent of events reported in 2016 that resulted in the death or unanticipated injury of a patient were related to “diagnostic process failure.” Factors in this classification included failures during each phase of the diagnostic process: assessment, history, testing, hypothesis generation, referral, and monitoring/follow-up. Understanding factors that contribute to errors during the diagnostic process is to key identifying opportunities for improvement.
Causes of errors
Many factors can lead to errors in diagnosis, including lack of collaboration and inadequate communication between providers and patients and their families and caregivers. Clinicians’ personal biases related to factors such as race, age, and gender can be another factor. The “Improving Diagnosis in Healthcare Report” provides several examples, including that women are more likely than men to have a missed diagnosis of myocardial infarction. Testing also plays a key role. The 2018 PSA study found that failures in the testing process were the most common reasons for diagnostic failure, accounting for 68.1 percent of events. The fact that errors may not be reported compounds the problem because the opportunity to learn from the mistake is lost.
Malpractice claims are another source of diagnostic error data that can help identify causes of errors, which can, in turn, help prevent them. In addition to the Nurse Practitioner Claim Report, the Nurse Practitioner Spotlight: Diagnosis provides further analysis of the nature of diagnosis-related malpractice claims. The Spotlight explains that most diagnosis-related claims relate to failure to order appropriate or needed diagnostic/laboratory testing to establish a diagnosis (30.2 percent of diagnosis-related claims). Other top allegation subcategories related to diagnosis are failure to timely/properly establish and/or order appropriate treatment (18.6 percent) and failure or delay in obtaining/addressing diagnostic test results (8.1 percent).
Understanding sources of errors is the first step to avoiding them. The next is to take a systematic approach to diagnosis, including assessment, testing, analysis, communication, monitoring, and follow-up. Collaboration supports this approach.
Collaboration is key
A major way to avoid diagnostic errors is ensuring that healthcare providers, patients, and their families and caregivers collaborate in the diagnostic process. Communication provides the foundation for that collaboration. In fact, the “Improving Diagnosis in Health Care” report defines a diagnostic error as the “failure to establish an accurate and timely explanation of the patient’s health problem(s) or failure to communicate that explanation to the patient” [emphasis added]. In other words, if patients don’t receive the information they need—and understand it—they can’t benefit.
Data collection through assessment
When a patient comes to the NP with a problem, the first step in making a diagnosis is to obtain a detailed history and perform a thorough assessment. The time pressures that NPs face can make it tempting to abbreviate this process but doing so can lead to diagnostic error and patient harm. Furthermore, careful data collection at this stage can end up saving time by facilitating rapid identification of the correct diagnosis, leading to more successful treatment interventions.
The history should include not only questions related to the patient’s current problem, but also those that address factors such as past and current medical conditions, family history, social history, medications (both prescription and over-the-counter), and dietary supplements. The NP also needs to review relevant notes from previous providers.
With the emphasis on testing often seen in the healthcare field, the importance of the physical exam has sometimes been downplayed. Yet, it is an essential tool for gaining valuable information and provides data that helps determine appropriate testing.
A patient-centered approach during the history and physical, including ensuring privacy, will help NPs obtain the information they need. Ensure that patients understand the rationale for the questions and exam and the importance of providing accurate information. NPs need to listen closely and tailor their communication to the patient’s needs and preferences.
Laboratory tests, radiography, and other tools help the NP make an accurate diagnosis. Testing may also include mental health assessment measures. The choice of tools should be based on the information gathered through the history and assessment. It’s also important to order and process tests correctly. For example, sufficient blood must be drawn for the ordered test, and the tube needs to be labeled and stored correctly before it’s transported to the lab. Samples also need to be delivered within the time frame specified for the test.
Choosing the correct diagnostic tools helps ensure the patient isn’t exposed to unnecessary testing, which can cause harm and drive up costs. One resource is Choosing Wisely, an initiative of the ABIM Foundation. The initiative is designed to facilitate discussion between clinicians and providers so that patients choose care that is supported by evidence and truly necessary. Various national organizations have identified unnecessary testing; these are available in a searchable database at https://www.choosingwisely.org/clinician-lists/.
The 2018 PSA study found that the most common reason for testing process errors was misreading or misinterpreting results. This supports the need to consider test results within the context of the patient’s signs and symptoms. If there seems to be a mismatch between the results and what might be expected based on data from the history and physical, the NP should consider repeating the test.
Once data from the history, physical exam, and tests are in hand, the next step is to determine the potential diagnosis or diagnoses. More information from the patient and additional testing may be needed before the diagnosis is finalized.
During the analysis, NPs should be aware of possible biases that may affect making the correct diagnosis. For example, the “Improving Diagnosis in Health Care” report notes that clinicians may miss a depression diagnosis in older adults because they assume this population is not as interested in interactions as younger patients. Another example is the clinician who attributes physical symptoms to a psychological source because the patient has a substance use disorder.
It’s also vital that NPs don’t rush the process. Taking time to thoroughly analyze and reflect on information obtained is essential for obtaining a correct diagnosis. Again, it may be helpful to consider whether the information matches what would be expected. For example, do the glucose levels truly reflect what is seen in patients with diabetes? NPs should consider how confident they are with the diagnosis; a lower confidence might prompt further testing or consultation with other providers.
To help improve the diagnostic process, consider potential unintended consequences of pursuing a specific diagnosis:
- Are factors present that do not align with the diagnosis?
- Are there elements that cannot be explained?
- Are there symptoms that are inconsistent with the current diagnosis?
- Is there a life-threatening condition with similar signs or symptoms that hasn’t been considered?
- Is it possible that there are multiple, concurrent issues ongoing?
Communication and follow-up
The 2018 PSA study found that monitoring and follow-up failures were associated with the highest risk of patient harm, so this step is vital. The NP should share potential and confirmed diagnoses with patients. This includes sharing test results and explaining how they relate to the patient’s signs and symptoms. Patients also need to receive a copy of their test results, whether through a secure patient portal or a paper copy, depending on the patient’s preference.
NPs also should share with patients how they arrived at the diagnosis. For example, an NP might note that she consulted with an endocrinologist to ensure she was correct in her analysis of the data and the conclusions drawn. This example has the added benefit of showing the patient that you are taking a team approach to their care. After the discussion, ask patients to explain to you what they believe the diagnosis is to ensure understanding.
The danger of missed and delayed diagnoses can be mitigated through appropriate follow up. For example, ensure that all test results have been received. Follow up may also include obtaining a second opinion, which should be shared with the patient. In addition, as a professional, the NP needs to be comfortable with transferring a patient to a specialist if a diagnosis is particularly challenging.
Patients play an important role in follow up. Give them specific instructions as to when they should contact a provider should their condition change. NPs typically think of this in terms of complications from existing diagnoses, but it also can help in identifying a condition that may have been missed on the initial assessment. NPs should also monitor patients for response to treatment interventions and revise the plan of care as needed.
In the Nurse Practitioner Claim Report
, one of the underlying threads for the diagnosis-related claims was the lack of documentation that supports the decision-making process related to diagnosis. The most common problems with missing or incomplete documentation related to:
- Lack of a complete patient and family history
- Incomplete physical assessment
- Failure to list current medications and/or complaints
- Failure to document patient nonadherence with appointments, ordered diagnostic tests and/or prescribed medications
- Absence of notification of diagnostic test results and recommendations for further treatment or testing
This is an excellent list for NPs to keep in mind when documenting in the patient’s health record. Other items include documentation of reports from specialists who have been consulted, results of tests, and any reassessment related to patients returning with signs and symptoms that have not been resolved or have worsened. For regular patients, it is also wise to update the history and physical examination regularly.
Remember that the goal is for another clinician to be able to follow the NP’s train of thought from signs and symptoms to test results to diagnosis.
Ensuring quality care
Diagnostic errors can cause harm to patients and result in NPs facing legal action. NPs can avoid these errors (and their negative effects) by conducting a thorough assessment, ordering appropriate tests, interpreting data obtained through assessment and testing, communicating results, and following up as indicated. This methodical approach will help protect patients and help nursing professionals mitigate their liability risks.
Tips to help avoid diagnostic errors
Follow these steps to help ensure you make the right diagnosis:
- Use mnemonics, checklists, templates (such as those for a physical exam), and other tools to ensure a complete, accurate assessment.
- Review prompts received in an electronic health record system (EHR). Don’t override a suggestion without careful consideration.
- Don’t practice in a vacuum. Radiologists, pathologists, nurses, and other clinicians all can have valuable insights.
- Consider a second opinion if you are unsure.
- Be aware of the danger of care transitions. If you are receiving a patient from another provider, double check to ensure you have the information you need. If you are sending a patient to another provider, provide a complete report.
- Empower your patients and encourage them to be active participants in their care. For example, encourage them to speak up if they don’t understand their test results. Patients also need to understand the importance of sharing all information with providers, including use of illicit substances.
- If you work in an office, lead initiatives to help ensure testing processes do not break down. An excellent resource is “Improving Your Laboratory Testing Process” from the Agency for Healthcare Research and Quality.
And don’t forget the basics:
- Annually review the nurse/nurse practitioner practice act in the state(s) where you hold a license.
- Practice in accordance with your organization’s policies and procedures.
- Practice within your scope.
Agency for Healthcare Research and Quality. Tools to improve diagnostic safety. n.d. https://www.ahrq.gov/professionals/quality-patient-safety/diagnostic-safety/tools.html
Balogh EP, Miller BT, Ball JR, eds. Improving diagnosis in healthcare. National Academies Press. 2015. https://www.ncbi.nlm.nih.gov/books/NBK338596/
CNA, NSO. Nurse practitioner claim report: 5th edition. 2022. https://www.nso.com/NPClaimReport
CNA, NSO. Nurse practitioner spotlight: Diagnosis. 2022. https://www.nso.com/getmedia/8d561f58-3230-47c7-a29b-1718cd885431/NSO_NP22_SL_Diagnosis_SEC.pdf
Jones R, Magee MC. Identifying and learning from events involving diagnostic error: It’s a process. Pa Patient Saf Advis. 2018;15(Supple 1):3-15. http://patientsafety.pa.gov/ADVISORIES/documents/201810_IdentifyingandLearning.pdf
National Quality Forum. Improving diagnostic quality and safety. 2017. http://www.qualityforum.org/Publications/2017/09/Improving_Diagnostic_Quality_and_Safety_Final_Report.aspx
World Health Organization. Diagnostic errors. 2016. https://apps.who.int/iris/bitstream/handle/10665/252410/9789241511636-eng.pdf;jsessionid=621373C9C6EEF5B5C6D0F9CB796C07CB?sequence=1
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