Largely, there has been a lack of attention paid to errors made in the diagnostic process.  It is true that this type of error is challenging to identify and analyze1, and is often more covert and multifaceted than other types of errors in medicine, such as surgical and medication errors.  Nonetheless, healthcare organizations need to monitor the diagnostic process more closely, and actively learn from the errors made in that realm to improve quality.

The context in which errors occur is important to study.  By studying the work system, areas of break-down can be identified; this places less focus on individuals and more focus on processes and the environment in which diagnostic errors occur.  A healthcare system can employ various techniques to study the work system when an error occurs, such as root cause analyses, fishbone diagrams, or morbidity & mortality (M&M) conferences2.  Sharing the outcomes of these studies with key players is imperative; identifying where and how the errors occur does no good if the healthcare employees have not been informed or allowed to learn from the experience.

The culture within a healthcare organization can “make or break” the success of a quality improvement or patient safety initiative.  A punitive culture may lessen the likelihood that an employee will report an error, and it may discourage conversations about break-downs within the work system and how to address these problems.  A just culture (a.k.a. a culture of safety) encourages learning from errors and celebrating successes, thereby leading to a more positive work environment and less “pointing fingers”3.

Laboratory professionals can engage in creating a just culture and a work system that supports the diagnostic process.  When we think about turn-around time, the total testing process loop (a.k.a. the brain-to-brain loop) is what should come to mind4.  We should modify how we integrate with clinicians by designing systems that increase the chances they will order the right test on the right patient at the right time, and assist in the timely receipt and interpretation of test results.  Laboratory leaders need to encourage their employees to broaden their focus and step outside their comfort zones to accomplish these tasks; only then will other healthcare professionals acknowledge and appreciate the expertise we have to offer.

1Graber, M. L., R. Trowbridge, J. S. Myers, C. A. Umscheid, W. Strull, and M. H. Kanter. 2014.  The next organizational challenge: Finding and addressing diagnostic error. Joint Commission Journal on Quality and Patient Safety 40(3): 102–110.

2National Academies of Science, Engineering, and Medicine.  2015.  Improving Diagnosis in Health Care.  Washington, D.C.: The National Academy Press.

3Davies, H. T. O., and S. M. Nutley. 2000. Developing learning organisations in the new NHS. BMJ 320 (7240): 998–1001.

4Plebani, M., M. Laposata, and G. D. Lundberg. 2011. The brain-to-brain loop concept for laboratory testing 40 years after its introduction. American Journal of Clinical Pathology 136(6): 829–833.