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Diagnostic Errors in Medicine
November 12, 2012
William Strull, MD
Medical Director
Quality and Patient Safety
The Permanente Federation, LLC
Prepared by: Bettygene Egan, MBA
Kaiser Permanente Regions
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Coded Closed Claims
Claims Distributions
Diagnosis
Payout Distributions
Diagnosis
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High-Level Categories
 Cognition
 Visual diagnosis
 Closing the loop/Follow-up
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Staff Engagement and Learning
 Communication down to the front line level
 Diagnostic Reliability and Improvement Initiative
Team and Committees (DRII)
 Risk Managers Operations Team
 Sentinel Event Risk Care Integration Team
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Analyze, Share, Prevent,
Inter-REgionally,
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Specimen Handling & Tracking

Anatomical Specimen Handling

Inter-Regional Specimen Tracking
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Specimen Handling
Anatomical
Pathology Specimen
Handling Project
Colorado Region
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CD Bio National Strategy
Background
• Lack of a uniform specimen tracking mechanism
throughout Kaiser Permanente has lead to lost or
misplaced specimens during transit or while being
processed at hospital or regional laboratories.
• Existing Specimen Tracking capabilities do not support
all specimen tracking needs for Kaiser Permanente’s
multi-site intra-regional laboratories.
• Some of the identified specimen tracking pain points
during specimen transport includes: specimens lost,
misplaced, misrouted, relabeled and stored at the
incorrect temperature resulting in unusable specimens .
Then they must be recollected when possible resulting
in missed or delayed diagnosis, and even litigation risks
when high value specimens are lost or mishandled.
• The consequence of a loss depends on the type of
specimen, varying from the irreparable impact of a lost
diagnostic specimen that can’t be recollected to the
inconvenience a member experiences being recalled for
a repeat blood collection.
• Ultimately, these lost specimens results in decreased
member and provider satisfaction, increased costs due
to repeated procedures or even worse, litigation.
Strategic Alignment
Strategic KP Imperatives
• Transform Care Delivery
• Solving for Affordability
Benefits Realization
• Continuous Improvement
• Productivity Gains
• Compliance Requirements
• Cost of Doing Business
• Member Satisfaction
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Identify and Manage
Outpatient Safety Nets that proactively identify and
manage patients with an outpatient safety risks
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Categories of Gaps
 Necessary Follow-up Care
 Tracking/follow-up of abnormal results
 Medication Management
 Appropriate monitoring for long-term medications
 Diagnosis Detection
 Identify potentially undiagnosed cases
 Potentially Harmful Interactions
 Pharmacist recommends alternative drug therapy
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Patient Safety Measurement
Portfolio
• % of breast cancer diagnosed at stage 1 or 2
• % of cervical cancer diagnosed at stage 1 or 2
• % of colorectal cancer diagnosed at stage 1 or 2
• Testing for HIV among HIV uninfected members
diagnosed with sexually transmitted infection
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KP HealthConnect

The After Visit Summary
• Improves patient follow through with the completion of diagnostic
tests
• Engages the patient as “partner”
• Is the #1 member satisfier

Overdue Results Notification
• Provides a safety net to ensure that tests are completed

“Tickler” Reminder Messaging
• Allows clinicians to send themselves a reminder to make sure an
urgent or important diagnostic test, referral or “hand off” has been
completed

In Basket Monitoring
• Ensures that all in basket messages, with abnormal results, have
been addressed in a timely manner
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Engagement
 Patient Family Centered Care
 SMART Partners
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Diagnosis and Engagement
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Diagnosis and Engagement
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Questions
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