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Finding and fixing diagnosis errors: can triggers help?
  1. Gordon D Schiff
  1. Correspondence to Dr Gordon D Schiff, Associate Director, Center for Patient Safety Research and Practice Division of General Internal Medicine, Brigham and Women's Hospital Associate Professor of Medicine Harvard Medical School 1620 Tremont St. 3rd Fl Boston, MA 02120; USA; gschiff{at}

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Imagine conferring with your clinician colleagues and being handed a plateful of all of your missed and delayed diagnoses. But, imagine further that, rather than a nightmare of ghosts returning to haunt you in the form of malpractice claims, sanctions by regulatory boards, insurers pouncing on needless expenditures or hordes (yes, there would be large numbers) of angry finger-pointing patients and families, the experience would instead bring a dream of supportive feedback and learning. Imagine the ways such an idealised non-threatening consultation and conference might be designed to minimise defensiveness and maximise introspection, learn lessons, and rethink habits and standard practices. Rather than prompting incredulous exclamations of “you missed that?!” or “what were you thinking?!”, the process would generate engagement and scrutiny of office and hospital workflow and diagnostic testing practices, realistically grappling with time and cost trade-offs, pressures, uncertainties and diagnostic challenges that practicing clinicians face every day. In short, your plateful of missed diagnoses would initiate a process that combines the best elements of a fun and informative morbidity and mortality conference, an expert second opinion from a generous colleague and productive quality improvement consultation.

I suspect the average clinician could care less about diagnostic ‘triggers’ or a new study to increase their positive predictive value. However, no professional could fail to see the appeal of the ultimate form of continuing medical education imagined above—learning practical lessons from one's own cases and discussing with trusted colleagues the ways care could be improved. How to get there from here poses a fundamental challenge, one that the study by Singh et al on diagnosis error ‘triggers’ in this issue of BMJ Quality and Safety attempts to address.1

The authors, a research team based at the DeBakey Veterans Affairs Medical Center and Baylor College of Medicine in Houston, have continued …

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