( 14 ) LEADING CHANGE ELIMINATING THE HIDDEN DRIVERS Using insights revealed by this self-assessment tool, your team can expose and begin to eliminate the hidden drivers of diagnostic error in your ED. Leading this change will involve identifying your ED’s unique vulnerabilities and implementing new protocols. It will require the commitment of the entire care team working together to implement solutions with consistent monitoring, continual adjustments, and ongoing vigilance. While this effort won’t be easy, it will be worthwhile. When you eliminate the drivers of diagnostic error, you will help reduce the harm experienced by patients, their loved ones, and their care teams. You will also help stem the tide of exorbitant medical practice liability costs and nuclear verdicts – and their impact on the ever-increasing cost of healthcare. Case studies and other patient examples shared in this publication are derived from actual malpractice claims with identifying details removed or altered to protect the anonymity of patients, families, healthcare providers, and healthcare organizations. The information in this report is intended to provide general guidelines for risk management. It is not intended as, nor should it be construed as, legal or medical advice. Copyright 2024, Coverys Five Key Steps RAISE AWARENESS Share this report to educate your team on the prevalence of diagnostic error, its causes, and how it can be prevented. 1 KNOW YOUR DATA Become a data sleuth. Ask for a review of your adverse event, patient experience, and culture safety data. Set measurable goals for improvement. 2 ENLIST AND ENGAGE Develop champions to vigilantly lead change, continually improving your most vulnerable areas. 3 EVALUATE AND MONITOR Stay on track, monitoring and sustaining best practices and holding teams accountable. 4 CONTINUOUSLY ADAPT Continuously adapt your practices to address emerging exposures. Monitor metrics to avoid complacency. 5 | HIDDEN IN PLAIN SIGHT | Exposing the Drivers of Diagnostic Error A DOSE OF INSIGHT ® Coverys |