Summary
Consider the following when implementing a diagnostic time out process in your organization.
More than a decade ago, the Institute of Medicine warned that most people will experience a diagnostic error in their lifetime, sometimes with serious consequences. Many respected organizations responded by issuing recommendations and guidelines designed to reduce the incidence of diagnostic error. Despite these efforts, diagnostic error remains a significant challenge—each year, an estimated 795,000 Americans die or become permanently disabled due to misdiagnosis.
Given the magnitude of harm associated with diagnostic error, it is not surprising that these failures also represent a significant source of malpractice claims. A review by the Coverys data analytics team of 6,009 medical malpractice events closed from 2020-2024, found that diagnostic error was the second most common allegation, representing 27% of all events. Notably, these cases accounted for 42% of all indemnity paid—the highest percentage of payments across all service settings.
The diagnostic process is a complicated one that involves collecting, integrating, and interpreting data to arrive at a working diagnosis. Diagnosticians typically move through the diagnostic process using two types of reasoning—analytical and intuitive. Analytical reasoning is methodical, deliberate, and rule based. Conversely, intuitive reasoning is rapid and based on unconscious correlation to previous experiences and examples stored in memory. While this can be helpful in situations like choosing what movie to watch, when diagnosticians rely too heavily on intuitive reasoning in the diagnostic process, it can reinforce cognitive biases that distort clinical judgment and contribute to diagnostic error.
One common example of cognitive bias in the diagnostic process is anchoring, in which a practitioner fixates on an initial impression and fails to adjust as new information emerges. For example, when a patient with a history of congestive heart failure presents with shortness of breath, the clinician may presume that this symptom is due to an exacerbation of that disease process and overlook evolving signs and symptoms of a pulmonary embolus. This narrowing of focus illustrates how intuitive reasoning can distort judgement in the diagnostic process.
A growing strategy to counter overreliance on intuitive reasoning in the diagnostic process is the diagnostic time out (DTO). Just as the surgical timeout creates a deliberate pause to prevent procedural errors, the DTO creates a deliberate pause to prevent diagnostic error. Specifically, the DTO is an evidence-based intervention designed to prompt practitioners to pause and methodically reassess their working diagnosis, evaluate alternative explanations, and fully consider critical data before finalizing clinical decisions. The Centers for Disease Control and Prevention has included DTO in its Core Elements of Hospital Diagnostic Excellence as a practice that strengthens diagnostic accuracy and reduces preventable harm.
Diagnostic error is a persistent problem in healthcare organizations. Introducing a DTO process can be a practical way to apply a more analytical approach to the diagnostic process, counter cognitive bias, and support safer, more accurate decision-making. Consider the following when implementing a DTO process in your organization:
Given the magnitude of harm associated with diagnostic error, it is not surprising that these failures also represent a significant source of malpractice claims. A review by the Coverys data analytics team of 6,009 medical malpractice events closed from 2020-2024, found that diagnostic error was the second most common allegation, representing 27% of all events. Notably, these cases accounted for 42% of all indemnity paid—the highest percentage of payments across all service settings.
The diagnostic process is a complicated one that involves collecting, integrating, and interpreting data to arrive at a working diagnosis. Diagnosticians typically move through the diagnostic process using two types of reasoning—analytical and intuitive. Analytical reasoning is methodical, deliberate, and rule based. Conversely, intuitive reasoning is rapid and based on unconscious correlation to previous experiences and examples stored in memory. While this can be helpful in situations like choosing what movie to watch, when diagnosticians rely too heavily on intuitive reasoning in the diagnostic process, it can reinforce cognitive biases that distort clinical judgment and contribute to diagnostic error.
One common example of cognitive bias in the diagnostic process is anchoring, in which a practitioner fixates on an initial impression and fails to adjust as new information emerges. For example, when a patient with a history of congestive heart failure presents with shortness of breath, the clinician may presume that this symptom is due to an exacerbation of that disease process and overlook evolving signs and symptoms of a pulmonary embolus. This narrowing of focus illustrates how intuitive reasoning can distort judgement in the diagnostic process.
A growing strategy to counter overreliance on intuitive reasoning in the diagnostic process is the diagnostic time out (DTO). Just as the surgical timeout creates a deliberate pause to prevent procedural errors, the DTO creates a deliberate pause to prevent diagnostic error. Specifically, the DTO is an evidence-based intervention designed to prompt practitioners to pause and methodically reassess their working diagnosis, evaluate alternative explanations, and fully consider critical data before finalizing clinical decisions. The Centers for Disease Control and Prevention has included DTO in its Core Elements of Hospital Diagnostic Excellence as a practice that strengthens diagnostic accuracy and reduces preventable harm.
Risk Recommendations:
Diagnostic error is a persistent problem in healthcare organizations. Introducing a DTO process can be a practical way to apply a more analytical approach to the diagnostic process, counter cognitive bias, and support safer, more accurate decision-making. Consider the following when implementing a DTO process in your organization:
- Identify triggers. Ensure that the DTO process defines when to initiate a DTO, such as unexpected patient deterioration, repeated requests for medication refills, misalignment of test results with the working diagnosis, failure to respond to treatment or when diagnostic uncertainty exists. These triggers are clues that the working diagnosis may be inaccurate and require further investigation.
- Standardize the process. Develop a concise, evidence based structure for the DTO process that guides practitioners through a consistent set of steps—reassessing key diagnostic data, revisiting the differential diagnosis, and considering the influence of cognitive bias on the diagnostic process. A standardized approach using structured tools ensures consistent process application and helps integrate deliberate methodical analysis into the diagnostic process.
- Encourage participation. Diagnosis is a team effort. Practitioners, nurses, and other care team members each have pieces of information that are important to the diagnostic process, from changes in vital signs to subtle clinical clues to workflow insights. A DTO works best when everyone on the team feels empowered to contribute their observations and perspectives to the discussion.
- Embed the process. Integrate the DTO process into routine activities like rounds and handoffs to reduce disruption, increase feasibility, and normalize the process. When the process is woven into everyday workflow patterns, it becomes easier for teams to consistently adopt and sustain over time.
- Provide leadership support. Strong endorsement and support from leadership can transform the DTO process from just another “initiative” into a meaningful safety practice and a cultural norm. Foster an organizational culture in which diagnostic uncertainty is an accepted part of the diagnostic process so that practitioners feel comfortable questioning and reassessing without fear of reprisal. Champion the DTO process as a fundamental patient safety practice that is a strength rather than a sign of incompetence.
- Monitor outcomes. Conduct regular audits to ensure that DTOs are conducted consistently and as intended. Elicit practitioner feedback to determine whether there are opportunities for process improvement or workflow issues that are impacting implementation. Review claims data and diagnostic safety events, including near misses, to evaluate program impact and determine if fine-tuning is needed.
Copyrighted. No legal or medical advice intended. This post includes general risk management guidelines. Such materials are for informational purposes only and may not reflect the most current legal or medical developments. These informational materials are not intended, and must not be taken, as legal or medical advice on any particular set of facts or circumstances.