Table 2.

Participant Quotes by Theme

Barriers to diagnostic safety themes	n(%)	Representative quotes
1. Diagnostic safety culture	19(59%)	“When we call in medical staff quality committee to discuss an event…It’s an embarrassment...Diagnosis, as you know, with physicians is tied to your identity to some degree, and so these things are hard to discuss.” (R037) “I’m trying to be as transparent as possible, I would say the culture has been rather punitive when it comes to error, and not just diagnostic error but any kind of error…”. (R042) “Most of us work under a lot of time pressures and workflow issues that really require us to keep moving, and often times, transparency, especially transparency with your thought process of making a diagnosis, takes time and energy that could wear you down.” (R037)
Positive comments/recommendations	18(56%)	“We have a safety initiative in place that we refer to as we ARE safe, which stands for accountable, reliable, and empowered, and as part of that initiative, we promote certain safety behaviors that are intended to be high reliability practices that reduce the likelihood of human error.” (R059) “We talked about the safety at our departmental meetings and at our general staff meetings. We talk about our serious safety event rate, and so we are being more transparent with that and trying to develop more of a just culture where people feel comfortable reporting....” (R038)
2. Infrastructure for measurement, monitoring, and improvement activities
Measure and monitor diagnostic errors	25(78%)	“We haven’t really figured out our tools, haven’t measured it…You get a measure and then there’s no benchmark. We don’t know what the rate is…we haven’t been able to design the right kind of net to capture those things.” (R049) “We have a deep understanding of machine learning and artificial intelligence, and I think that we are really on the cutting edge ….so that piece, the technology is phenomenal…using digital tools to support the cognitive skills of providers.” (R054) “We know from some of our surveys that physicians don’t really think that they make errors. They don’t really appreciate how often they make diagnostic errors. That’s a big barrier so they don’t self-report and then you [have to] rely on other people to capture them.” (R049)
Positive comments/recommendations	8(25%)	“We do have rewards and recognition for people who do the right thing. We do try to set some goals for physician reporting each year to try to increase physician reporting.” (R050)
Unclear process to address diagnostic errors cases	13(40%)	“The main thing is that there is not a ready process that we can point to and say we need to be doing this about diagnostic error. Right now, we’re sort of floating, and we’re not doing what we need to be doing...” (R037) “There isn’t a lot of infrastructure that kind of guides…the best practices for an institution to track and respond to diagnostic events.” (R072) “Here at this organization, we’re very reactive and not proactive, so a lot of our stuff is retrospective instead of being able to dig into the data yet to be proactive and identify opportunities before they happen.” (R062)
Positive comments/recommendations	6(18.7%)	“They [physicians] worked with our IT department and built a smart phone app that links to the electronic medical record…we put this smart phone-based diagnostic error reporting system in the hands of the physician where we’re collecting additional cases that are largely fodder for their M and M’s [morbidity and mortality conferences]. We’re increasingly using those in places where we learn and make systems improvements.” (R040)
Limited sharing of findings and feedback	13(40%)	“The most important far and away is to provide clinicians with feedback about their diagnosis performance so they know whether they’re right or wrong, because if we can’t give people feedback, they can’t get better.” (R048) “We actually still are struggling I believe with having good mechanisms in place to share learning from M&Ms and sometimes it’s been RCAs more broadly across the organization. It’s something that we’re aware of and have been actually working this year to figure out ways to better spread the learning’s. But right now, we’re still in a situation where we don’t do a good job of that.” (R055)
Positive comments/recommendations	9(28%)	“We encourage people to put their names in when they report things and we make sure that we give them feedback, so they know we just didn’t put a piece of paper in a box or file an electronic thing and then nobody ever pays attention to it. We give direct feedback to what…would be corrective action based on what they reported.” (R041)
3. Leadership investment	9(28%)	“The attention of leadership seems to be focused on easy, low-hanging measures that do wind up determining your scores that are publicly reported. The diagnostic error, I think has not been framed as neatly as it can be.” (R050) “I think that at a leadership level, there is an understanding that this [diagnostic safety] is important, but…how to actually translate that into action is still something that leadership is considering…” (R061) “I think it’s at the governance level, particularly at the Board level. As I say, once in a while we’ll have a presentation on diagnostic error; it grabs everyone’s attention, but then they’re back to looking at your surgical site infection rates, we have not transitioned to a point where it gets consistent and regular attention.... there’s institutional awareness, but it has not been a leadership priority, not only awareness but efforts to intervene or change the tide so to speak.” (R055)
Positive comments/recommendations	4(12.5%)	“It’s really about having those leaders come to the steering committee with the others on a monthly basis to update and let us know. So, the board is very in tune, and I think that we’ve done a very good job of that.” (R040)
4. Diagnostic safety teams that work on diagnostic safety	18(56%)	“There’s no standing team… to deal with cases of diagnostic error. The teams are always ad-hoc and include representatives from risk, quality department, and medical leadership.” (R051) “One of the challenges in our health system is resources and the budget and all those kinds of things so we are very resource constrained.” (R070) “I think that the coordination between teams is one of the most challenging things we deal with. I think that all the way from…who’s on the team and what are the roles and responsibilities. Those are not defined well.” (R048)
Positive comments/recommendations	12(37%)	“I would say cultivating local expertise across your institution, so having people who are up to date on the literature and engaged…so having representatives on an institution-wide committee on diagnosis that come from the ED, from the inpatient setting, from subspecialty care, from ambulatory clinics, because I really think that this is a multifaceted problem that doesn’t just live in one clinical context.” (R072)