Diagnostic safety and excellence
At about this time last year, I travelled to the beautiful city of Geneva, Switzerland with its lake and surrounding mountains. I was there to attend the World Health Organization (WHO) global consultation for World Patient Safety Day 2024 on improving diagnostic safety and implementing the Global Patient Safety Action Plan 2021-2030.
Sir Liam Donaldson, the WHO envoy for Patient Safety, opened the event reflecting on his 25 years as a champion of patient safety. He noted that in the early days, the patient safety movement was made up of a small group of dedicated academics. Today, patient safety is increasingly mainstream and seen as ‘everybody’s business.’ Avoidable patient harm is viewed as relevant to all of us, affecting clinicians, patients, parents and relatives.
Associate Professor Carmel Crock attended the World Health Organization (WHO) global consultation for World Patient Safety Day 2024 held in Geneva, Switzerland.
Why have a World Patient Safety Day each year?
Since 2019, 17 September has been designated and celebrated as World Patient Safety Day.
It may seem a strange concept to celebrate or commemorate patient safety, but there’s good reason for dedicating a day each year to raise awareness of patient safety. Healthcare is inherently risky and increasingly complex. Keeping patients safe is an essential part of what we do. Yet about 1 in 10 patients is harmed by the very healthcare that is intended to help them. And about half of this harm is thought to be preventable.
“World Patient Safety Day provides a unified focal point for global solidarity and concerted efforts to improve patient safety.”
Acknowledging that patient safety concerns us all and that we can reduce harm is an important first step. World Patient Safety Day provides a unified focal point for global solidarity and concerted efforts to improve patient safety.
World Patient Safety Day aims to encourage countries around the globe to organise national campaigns and hold special events for stakeholders to discuss themes, identify key approaches and reconfirm their commitment to patient safety. Each country has different patient safety challenges, but we can share and learn from each other’s challenges and experiences.
The day also focuses on discussing and debating the Global Patient Safety Action Plan 2021-2030, which provides a framework for action to eliminate avoidable harm in healthcare. As a mark of solidarity, each year countries, cities and hospitals light up iconic monuments and public places in orange. In Geneva, the famous Jet d’Eau (pictured above) on Lake Geneva was lit up on September 17 last year and in Canberra, Australia’s old and new Parliament House buildings were lit up in orange (pictured below). Each year World Patient Safety Day adopts a theme to draw attention to a particular patient safety concern.
Past themes have included speaking up for patient safety, health worker safety, medication safety and engaging patients for patient safety. In 2024, the theme for World Patient Safety Day was “Improving diagnosis for patient safety.”
At the global consultation I attended, which occurred just prior to World Patient Safety Day, we discussed the now well-established field of diagnostic safety, as well as diagnostic stewardship and excellence. Global inequities in the diagnostic process and the challenges faced by middle- and low-income countries were highlighted. Key ideas which were discussed included improving diagnosis and highlighting why they are important for us as emergency medicine clinicians.
What is diagnostic safety and why focus on it?
Although diagnosis has long been recognised as a crucial part of healthcare, the concept of diagnostic safety is a more recent development.
Diagnostic safety refers to accurate timely diagnosis that is communicated to the patient with appropriate use of resources.
Efforts to make healthcare safer have to date focused mainly on areas such as surgical safety, medication safety and healthcare-associated infections, which can be more easily measured and monitored. Yet about 1 in 10 diagnoses is inaccurate or delayed. Diagnostic error contributes to the global burden of unsafe care.
The aim of the WHO World Patient Safety Day on improving diagnosis and diagnostic safety was firstly to raise awareness that errors in diagnosis contribute significantly to patient harm worldwide. The consultation strongly focused on empowering patients and families to engage with healthcare workers and leaders to improve diagnostic processes.
To reduce the burden of diagnostic errors and harm, the WHO suggested building on proven strategies from other areas of patient safety, such as medication safety and procedural safety, applying a human factors lens and systems thinking to the diagnostic process.
What sort of interventions could we use to improve diagnostic safety?
Every step of the diagnostic process can be targeted for interventions - including taking a patient history, clinical examination, use of diagnostic tests (diagnostic stewardship), coordination of processes, and communication between team members, as well as referral mechanisms. Use of diagnostic pathways and clinical decision support can improve the work of diagnosis.
Should we be measuring and monitoring diagnostic safety?
Diagnostic safety events refer to delayed, wrong or missed diagnosis or when a diagnosis is not communicated to the patient. These events should now be measured and monitored alongside other patient safety events currently reported.
Methods to measure and monitor safety in the diagnostic process include patient feedback, feedback and reporting of diagnostic safety events by clinicians, audit of test ordering for appropriateness, adherence to diagnostic pathways and clinical practice guidelines, and rates of delayed and misdiagnosis for high-risk conditions.
It is well worth having a look at the resources developed by the WHO on diagnostic safety and the recordings from the consultation. These resources provide a useful introduction to the field of diagnostic safety.
They are available on the WHO website.
How do we optimise diagnostic safety and excellence in emergency departments?
At the best of times, diagnosis can be difficult and complex. It’s hard to imagine a more challenging environment than the ED for the diagnostic process to unfold. Our patients are undifferentiated, usually not known to us, and may be critically unwell and unable to provide a history. We are constantly interrupted, and we manage multiple patients at the same time. There are language barriers. We see the full spectrum of pathologies and disease presentations. We have critical issues such as access block and ED overcrowding which affect the diagnostic journey of our patients. And yet we achieve diagnostic safety much of the time.
“In EDs we work in teams, so the diagnostic process is a team process. Great teamwork, communication and handover help keep diagnosis safe. ”
Diagnostic safety in the ED is often about managing competing priorities. It’s about understanding and communicating the high degree of diagnostic uncertainty that we encounter on initial presentation, having a working (most likely) diagnosis, and considered differential diagnoses, including ruling in or out the worst-case scenario. It’s about careful, directed history-taking using all available sources, and directed examination and judicial test ordering. It often entails waiting and watching, asking a colleague for their opinion, and knowing when to access expertise.
In EDs we work in teams, so the diagnostic process is a team process. Great teamwork, communication and handover help keep diagnosis safe. Our handovers also provide an essential time for reviewing the diagnosis and managing it with fresh eyes.
Knowing about our recurrent diagnostic pitfalls (such as stroke presenting with dizziness, aortic dissection, epidural abscess, pulmonary embolism and subarachnoid haemorrhage) and getting feedback on our diagnoses are both crucial. Learning from both diagnostic excellence and diagnostic error is needed.
“As ED clinicians, one of our crucial roles is helping patients to understand the role of ED in diagnosis. ”
As ED clinicians, one of our crucial roles is helping patients to understand the role of ED in diagnosis. We spend quite a lot of time explaining to patients our thought processes and sharing our uncertainty with them. These are some of the ways we safety net our diagnostic process, ensuring that our patients understand that things may change, their illness may evolve and that diagnostic possibilities can change over time. We often explain to patients the reasons why we think it is or isn’t a particular diagnosis, why a certain test is needed or not needed. Clarifying our thought processes with patients helps to create a shared mental model with our patients of what diagnostic safety looks like.
Much of the time, diagnostic safety and excellence in ED does not mean making a diagnosis nor getting it right – rather it involves engaging in every step of the diagnostic process in a considered way, listening to and communicating thoughtfully with our patients, families and colleagues, ensuring our processes and coordination of care are reliable – and doing all this while keeping an open mind.
World Patient Safety Day 2025
This year’s World Patient Safety Day theme is ‘Safe care for every newborn and child’. Look for buildings lit up in orange in your area to mark the day.
Patient safety takes a team. World Patient Safety Day is an opportunity to refocus and enhance our dedication to achieve safer care for our patients and the wellbeing of our healthcare teams.
