% Events % Indemnity Paid N=381 diagnostic-related events in the ED closed 2019-2023. KEY VULNERABILITIES IN THE ED DIAGNOSTIC PROCESS 46% 42% 27% 34% 17% 14% 4% 3% 3% 1% 2% 5% H&P Evaluation Test Interpretation Test Ordering Referral Management Receipt/Transmittal Results Follow Up with Patient ED SPOTLIGHT INSIGHTS FROM CLOSED ED CASES ( 4 ) The diagnostic process of care involves a series of steps from evaluation of the initial patient presentation to the development of a working— and eventually final—diagnosis. Each step builds on the insights of the previous, a process that can be particularly challenging in the fast-paced and rapidly evolving environment of the ED. Coverys data from closed malpractice events reveals that the top two categories in the process of care that are most vulnerable to error involve patient assessment and test interpretation. Key vulnerabilities in the diagnostic process in the ED Failure to obtain an adequate history and physical (H&P) is the most frequent contributor to diagnostic error in the ED, which is a critical prerequisite for establishing a complete differential diagnosis and ordering the correct tests. The devastating consequences of diagnostic error Diagnostic error in the ED can have devastating consequences. Our data shows that that 52% of diagnosis-related events in the ED resulted in death (36%) or a high-severity injury (16%). Events involving death accounted for 51% of the indemnity paid. 52% of diagnosis-related events in the ED resulted in death or high-severity injury. Injury severity definitions: High: Major and permanent injuries that result in loss of function. Medium: Injuries that can be resolved with a subsequent surgical procedure or medical treatment. Low: Injuries that are minor and may require additional treatment but have no complications or long-term physical effects. Common myth: There’s a general belief that only the most severe events lead to claims. Our data reveals that 48% of malpractice events arise from low- and medium-severity cases. | HIDDEN IN PLAIN SIGHT | Exposing the Drivers of Diagnostic Error A DOSE OF INSIGHT ® Coverys |