Graber et al (2002) proposed a three-part framework for considering diagnostic errors that includes: 1) errors of uncertainty, 2) errors caused by system factors, and 3) errors of thinking and reasoning.711 While these categories have significant overlap and should not be considered exhaustive, they provide a useful framework for considering the types of interventions that can be used to address each.
Errors of uncertainty are ones that may be particularly challenging to diagnose due to patient refusal of testing, limitations in medical knowledge, or unusual disease presentation.7 These errors may be challenging to systematically address, but as the errors arise, providers should be sure to discuss and debrief them (promoting a culture of learning from mistakes is discussed within Safety Systems, below).
System factor errors are related to problems within the health facility or larger health system. For instance, system errors may occur due to poor communication between staff, delays due to provider absenteeism, or lack of availability of diagnostic equipment. Like errors of uncertainty, these errors should be debriefed with the relevant stakeholders, and tools such as process flow mapping or root cause analysis may be particularly relevant for identifying the drivers of these errors.
Errors of thinking and reasoning has significant overlaps with competence. Diagnostic errors related to thinking and reasoning may be of particular concern during redistribution of roles and responsibilities or task shifting if providers are not given appropriate training. Strategies for addressing competence are discussed in the provider competence module, but a few options include: strengthening pre-service and in-service education, enhanced supervision, and the use of decision-making tools.711