Ep #142: Prevent Diagnostic Errors in NP Practice: Essential Strategies

Welcome to the Real Deal Nurse Practitioner Club, the podcast for nurses who are ready to pass their boards and thrive in their careers as real deal nurse practitioners. I’m Anna and I’m the Director of Nursing Content at Blueprint Test Prep. Whether you’re deep in exam prep or stepping into practice, I’ve got you. It is time to become the confident, knowledgeable NP that you’re meant to be. Let’s dive in.

Hey, hey everyone. For today’s episode, we are going to talk about something you’re probably not prepared for in school. Right, in NP school, you are taught to assess, diagnose, and treat as an advanced practice provider. But what happens when you don’t get that diagnosis right the first time? In clinical practice, it’s no longer just choosing the wrong answer on an exam, right? It’s treating an actual person. So, for you all today, we are going to talk about what diagnostic errors are and ways to prevent them. And my friend Courtney, who has been on the podcast once before, is with me today to talk more about this topic too.

Courtney: Hi everyone. It’s great to be here. We’ve been getting some requests to take some deeper dives into practice issues that NPs face. So I’m super excited to get to talk to you all about this today. No one wants to think about making a mistake in practice and potentially harming a patient, but it is something you might face once you’re out there as a real deal NP.

Anna: Yeah, absolutely. And the first thing I really want to do before we get into the nitty gritty of diagnostic errors is just share a little advice that was given to me by a colleague. I can’t even remember what was concerning their patient, but for whatever reason, my colleague just didn’t have that diagnosis within the 15-minute time slot. Right? And that can totally happen, especially at the beginning or in more complex cases. And when we talked about how stressful this can be, she said, “You’re not taking a test anymore. You don’t have to have all of the answers at once.” And not every situation can just be split between four possible answer choices. Sometimes you just need to get more information.

Courtney: So what did you take that to mean?

Anna: Well, as safe and competent real deal NPs, we shouldn’t be missing any of those big alarm findings or life-threatening diagnoses, right? But in general, it’s totally fine to order some labs or diagnostics or treat with a reasonable management plan and then bring the patient back in a few days. And I think that’s just really good wisdom to remind yourselves of when you’re just starting out.

Courtney: That is such good advice. I remember how it felt as a new NP seeing patients on my own, and sometimes I just wasn’t exactly sure what the diagnosis was. So thank you for sharing that story because I think that really ties into the topic for today. We may not always know all the answers right away, but how can we avoid common diagnostic errors and keep our patients safe?

Anna: Yeah, and just to clarify, if you all don’t quite know what I mean, diagnostic errors can mean that we misdiagnose someone, we created an unnecessary delay in diagnosis, or we missed a diagnosis or a condition altogether. The three main diagnostic errors, which are usually interrelated, are no-fault errors, system errors, and cognitive errors. So Courtney, do you want to start us off on these?

Courtney: Absolutely. So starting with no-fault errors, let’s talk about what that means. Based on the name, you might be able to already figure out what these type of diagnostic errors are. No-fault errors happen for reasons outside of the clinician’s control. So really, through no fault of someone.

Anna: Yeah, exactly. And can you share an example of a no-fault diagnostic error?

Courtney: The two most common examples are if a patient gives you misleading information, so they told you an incorrect medical history or deliberately withheld information that would have helped make the diagnosis, or the condition presents in such an atypical or odd way that any other reasonable clinician would miss the diagnosis too.

Anna: It always reminds me of episodes of House here, you know, where they’re trying to figure out the mystery and solve it of these crazy diagnoses or they withheld something. But I do want to add in here, no-fault errors are hard to prevent, right? Because sometimes they just happen. But as real deal NPs in real life, we should always be seeking to make sure we have the full picture. Sometimes our patients don’t tell us everything, and sometimes a disease might present in a really weird way. But we need to make sure that we are getting a very thorough history and we’re following our gut and we’re asking all of the questions.

Courtney: Exactly. If the patient is not getting better, then go back to the drawing board. Think outside the box. Order diagnostic testing if it’s reasonable, or maybe even consult a specialist for help.

Anna: Yeah, we can always, always ask for another opinion.

Now, the next type of diagnostic errors are systems errors. And that means there are problems within the healthcare system that cause errors and potential harm to patients. So, think of things like issues with communication between other team members, or policies that are really inefficient, or even issues with equipment.

Courtney: Yes, to help prevent system errors, you need to put on your patient advocate hat. So now, no employer or health system is perfect. There are always things that can be improved, but maybe you notice that there seems to be an issue with how referrals are done, or patients seem to be having difficulty making appointments for lab work.

Anna: Yeah, those are some really great points. Right, as an NP, part of our role is absolutely patient advocacy. So, outside of that 15 or 20-minute appointment, there are things that we can do to make things better and safer for our patients. And so I really just encourage you all to ask questions and join committees and be involved in the decisions that affect patient care. And there are so many different ways to make a difference as a nurse practitioner.

Courtney: For sure. That is so true.

So, lastly, let’s go over cognitive errors. Those are problems in the diagnostic process that the clinician makes. So maybe the clinician doesn’t have enough information or knowledge to make the correct diagnosis, or they develop tunnel vision with their thinking, or they didn’t get a thorough enough history or connect all the dots of the history and physical exam together.

Anna: Yeah, that tunnel vision is something that we really want to avoid, especially starting out. It’s so easy to see one symptom and we kind of jump to a diagnosis in our head of that one that we’ve seen in the textbook answer. But we know real life is not always the textbook answer. And not to sound scary, but there are a lot of areas of the diagnostic process where our thinking can just lead us in the wrong direction. So, let’s talk about some of the ways that we can prevent cognitive errors.

The most common cognitive error is called faulty synthesis. And essentially, it just means that the clinician isn’t putting the pieces of the puzzle together correctly. So this could be like not getting a thorough history of present illness, or asking a comprehensive review of systems. Or it could be that tunnel vision we just talked about about a particular symptom or a possible diagnosis.

Courtney: So what would be an example of that?

Anna: Well, that could be something like a patient reports a productive cough and a fever, and they have a history of smoking. Faulty thinking would be to focus only on infectious causes of the symptoms because of that fever and not asking more questions about the sputum and the past medical history. The clinician might diagnose the patient with pneumonia, but could possibly be missing a diagnosis of lung cancer or COPD.

Courtney: So the big thing to remember here is to keep an open mind and ask lots of questions. And then the other big type of cognitive error is when there is a lack of knowledge to be able to make the diagnosis. Not everyone knows everything about everything. So some ways that we can prevent these types of errors is to just ask for help. Consult a colleague, make a referral, use your continuing education money to attend a conference and learn a new skill, read journals, and stay up to date on the new guidelines.

Anna: Absolutely. You’re never expected to know it all, but as a nurse practitioner, you also never stop learning. And do not be afraid to ask for help. Use the other people around you. Use your resources. Be constantly looking things up.

And let’s go back to our advice from the beginning as we wrap things up. In clinical practice, you don’t have to know all of the answers all of the time. And while patient safety is always, always, always your top priority, errors do happen. Be thorough in your history. Do not rush through a patient exam. Stand up for better policies and procedures and having good equipment. Consult with your colleagues and ask questions. Never stop asking questions and never stop learning.

Courtney: Exactly. There will be times where you don’t get it right the first time, or you need to go back and get more information, especially as a new NP. That’s the reality of clinical practice, but like we just went over, there are ways to make sure errors don’t happen, or at least not as often.

Anna: Yep. And so that really wraps us up here. But thank you everyone for tuning in. I hope you enjoyed this short little episode today. Be sure to follow our podcast wherever you listen to podcasts. And you can find SMNP reviews on YouTube and social media. Until next time.

Thanks for listening to another episode of the Real Deal Nurse Practitioner Club. If you want more information about the different types of support that we offer to students and new nurse practitioners, you can visit npreviews, with an S, dot com. We’ll see you next week.