Implementation of diagnostic pauses in the ambulatory setting

Abstract

Background: Diagnostic errors result in preventable morbidity and mortality. The outpatient setting may be at increased risk, where time constraints, the indolent nature of outpatient complaints and single decision-maker practice models predominate.

Methods: We developed a self-administered diagnostic pause to address diagnostic error. Clinicians (physicians and nurse practitioners) in an academic primary care setting received the tool if they were seeing urgent care patients who had previously been seen in the past two weeks in urgent care. We used pre-post-intervention surveys, focus groups and chart audits 6 months after the urgent care visit to assess the impact of the intervention on participant perceptions and actions.

Results: We piloted diagnostic pauses in two phases (3 months and 6 months, respectively); 9 physicians participated in the first phase, and 16 physicians and 2 nurse practitioners in the second phase. Subjects received 135 alerts for diagnostic pauses and responded to 82 (61% response). Thirteen per cent of alerts resulted in clinicians reporting new actions as a result of the diagnostic pauses. Thirteen per cent of cases at a 6-month chart audit resulted in diagnostic discrepancies, defined as differences in diagnosis from the initial working diagnosis. Focus groups reported that the diagnostic pauses were brief and fairly well integrated into the overall workflow for evaluation but would have benefited as a real-time application for patients at higher risk for diagnostic error.

Conclusion: This pilot represents the first known examination of diagnostic pauses in the outpatient setting, and this work potentially paves the way for more broad-based systems and/or electronic interventions to address diagnostic error.

Keywords: cognitive biases; diagnostic errors; primary care.