Defining Diagnostic Excellence and Missed Diagnostic Opportunity for the Emergency Department Setting.

Abstract

To develop definitions of (1) diagnostic excellence and (2) missed diagnostic opportunity to guide research and quality/safety programs in the emergency department (ED). We used a modified RAND/UCLA panel method, which is a modified Delphi panel that is designed to measure consensus among clinical experts. First, we identified existing definitions of diagnostic error and related terms and extracted conceptual components (eg, accuracy and timeliness). Second, we recruited 11 multidisciplinary panelists, selected for diversity in professional role, clinical setting, geography, and diagnostic error exposure. Third, panelists rated conceptual components on validity, relevance to the ED, and overall importance using a 1 to 9 scale. Conceptual components with final-round median ratings ≥7 on all dimensions were selected for inclusion in narrative definitions. Diagnostic excellence in the ED is "the use of optimal, evidence-based practice to attain an accurate and timely explanation about a patient's condition based on the information available at the time and communicate that explanation to the patient/family. Diagnostic excellence is patient-centered and equitable. Diagnostic excellence includes avoidance of divergent practices. It leads to better choices in management, prevents missed opportunities, and reduces the risk of preventable patient harm." A missed diagnostic opportunity is "a measurable divergence from optimal, evidence-based practice that may lead to: an inaccurate or delayed explanation of a patient's condition, despite information available at the time, or a failure in shared communication related to the diagnosis with the patient/family. A missed diagnostic opportunity may lead to suboptimal management, preventable patient harm, or inequitable outcomes." Future work should study implementation of these definitions into ED diagnostic research and quality/safety programs.