In hospital care, few issues are as critical as ensuring accurate and timely diagnoses. Diagnostic errors can have profound and sometimes devastating consequences for patients and their families. At The Leapfrog Group, we are dedicated to advancing patient safety and improving diagnostic practices across the health care system.
In the "Recognizing Excellence in Diagnosis: Recommended Practices for Hospitals" report, we’ve outlined 22 key practices aimed at reducing diagnostic errors and enhancing patient safety. This comprehensive guide draws on insights from hospital leaders, patient advocates and patient safety experts like Sue Sheridan, a founding member of Patients for Patient Safety U.S., Leapfrog Board Member and member of Leapfrog’s Patient and Family Caregiver Expert Panel.
Sue Sheridan’s personal experiences with diagnostic errors—stemming from her son Cal’s severe brain damage due to untreated jaundice and her late husband Pat’s tragic death from a malignant tumor that went undiagnosed—highlight the urgent need for systemic improvements. Her compelling story underscores why Leapfrog’s commitment to patient safety and transparency is so vital.
In this video interview, Sue shares her insights on Leapfrog’s recommended practices with Jean-Luc Tilly, Leapfrog Program Manager. Sue highlights the importance of patient and family engagement, the need for robust monitoring of diagnostic safety events and the critical role of transparent error disclosure.
Join us as we explore how these recommendations can make a significant difference in reducing diagnostic errors and improving outcomes for patients and families. For a closer look at the report and how these practices can transform patient care, visit the Recognizing Excellence in Diagnosis website.
Jean-Luc Tilly: Hi, Sue, thanks for joining me today. I’m Jean-Luc Tilly, the Program Manager for Healthcare Ratings at The Leapfrog Group.
Today, we'll be speaking with Sue Sheridan, a founding member of Patients for Patient Safety US and a member of our Patient Family Caregiver Expert Panel at Leapfrog. Sue has been actively involved in our Recognizing Excellence in Diagnosis initiative, which includes a recently released report outlining best practices for hospitals to reduce diagnostic errors and harm to patients.
Sue, could you tell us a bit more about your connection with Leapfrog?
Sue Sheridan: What draws me to Leapfrog are really two issues. First, since its inception, Leapfrog has maintained a laser focus on patient safety, particularly diagnostic safety. While other organizations and government agencies have drifted away from safety, Leapfrog has not taken its eye off the ball. I applaud your leadership, as I’ve watched them over the years.
Second, I appreciate Leapfrog's commitment to transparency. As a mom who often leads our family’s health care decisions, I want to be empowered with information about hospitals. This transparency allows me to compare hospitals and make informed choices about where my family and I receive care. These two aspects—patient safety and transparency—are what draw me to Leapfrog.
Jean-Luc Tilly: I understand you have a personal story about a diagnostic error. Could you share that with us?
Sue Sheridan: Yes, I have two significant stories. My journey into patient safety began 29 years ago with the birth of my son, Cal. Despite a normal delivery and pregnancy, Cal suffered brain damage at five days old, in the hospital, due to a failure to recognize and treat his severe newborn jaundice. This oversight led to a series of events where Cal didn’t receive timely care, resulting in significant cerebral palsy, hearing impairment, speech impairment, and mobility issues. The failure to educate me about warning signs, acknowledge my concerns and to follow evidence-based guidelines is ultimately what led to Cal’s harm.
Four years later, my late husband, Pat, experienced a diagnostic error when a malignant tumor in his neck was not communicated to his neurosurgeon or us. This error caused the tumor to metastasize through Pat's spinal column, leading to his death at 45. At the time, Cal was six, and my daughter was two. These experiences highlight systemic failures, such as not closing the loop on pending test results and not informing us adequately, which motivated my commitment to improving patient safety and my involvement with Leapfrog.
Jean-Luc Tilly: Thank you for sharing that, Sue. Our report, "Recognizing Excellence in Diagnosis: Recommended Practices for Hospitals," includes 22 recommendations for reducing diagnostic errors. Could you highlight which recommendations you believe are most important for patients and family caregivers?
Sue Sheridan: All 22 recommendations are important and work together to enhance diagnostic safety. However, from my perspective, a couple stand out. First, patient and family engagement is so important. Hospitals need to give patients the right information, provide access to medical records, invite them to be part of the diagnostic process and offer mechanisms to report and escalate concerns. This engagement helps ensure that patients are informed and involved in their care. We need to create infrastructures at the hospital level to help the health care system redesign itself and center patients’ needs.
Another key recommendation is the measurement and monitoring of diagnostic safety events. When these events are not tracked, they become invisible, compromising patient safety. Hospitals must measure and monitor diagnostic errors to address and prevent them effectively.
Finally, disclosure of diagnostic errors to patients and families is vital. If hospitals are not transparent about these errors, they get buried, which perpetuates unsafe practices.
Jean-Luc Tilly: Thank you, Sue. You’re absolutely right that these different practices can work together to improve outcomes and reduce harm. Your insights are invaluable, and I appreciate you highlighting these important areas of our new report. For more information, visit leapfroggroup.org.
Sue Sheridan: Thank you, Jean-Luc.