Spring 2023: Patients Partner with Lakewood Health System to Reduce Diagnostic Errors Through System Redesign
Diagnostic errors — the failure to establish and communicate an accurate and timely explanation of the patient’s health problem — is a significant problem in health care. Whether a diagnosis is delayed, wrong, or missed, the outcome can be grave for patients and providers.
In partnership with the University of Minnesota, MMCI, Constellation, StratisHealth, and MAPS, Lakewood Health System undertook a project to decrease diagnostic errors by co-designing a new process to minimize the possibility of test result follow-up system failures that result in diagnostic errors. The project focused on diagnostic test follow-up in high-risk transitions of care for three specific tests: chest CT, chest X-ray, and blood/urine cultures.
The research began in 2019 with mapping of the current workflow for each test, chart reviews, and community surveys.
COVID hit in early 2020, and the project was delayed. But in March 2022, work resumed. Utilizing the data gathered in 2019, the next step was to take the identified opportunities for process improvement and to create an optimal future state for each of the three diagnostic tests.
Over two days in July 2022, the Lakewood team gathered at their facility in Staples, MN to create new process maps that would deliver increased reliability, safety, and efficiency.
From the beginning, the Lakewood organization’s leadership recognized the importance of including the perspective of patients and families to create a new process that is reliable, safe, and efficient. As a result, patients and community members were also part of the team. In addition to Lakewood area patients, two MAPS patient partners were also invited to join the July meeting. Along with Lisa Juliar of MAPS, Pat Lambert and I traveled north to join the team.
In addition to our volunteer work with MAPS, both Pat and I have been involved in several similar process redesign projects. These can be challenging in many ways, but the process utilized and results achieved by Lakewood was the best each of us had ever experienced.
The right people were in the room, with each part of the process represented, and everyone came with an openness to all ideas. There were no “silos”, territorial defensiveness, or protection of the status quo. The focus of all involved was on the patient and improving the process to reduce diagnostic errors and their impact on patients. The session was brilliantly organized and facilitated by Missy Lindow, Lakewood’s Director of Operations.
What we witnessed was how the often-frustrating complexity of health care can be improved through relentless commitment and collaboration. In a remarkably short amount of time, the new process flows for chest CT, chest X-ray, and cultures emerged; all tremendously improved over the former process flows.
Both Pat and I were grateful for the opportunity to be involved in this important patient safety project. In addition to contributing our perspectives as patients, we also got to witness first-hand the challenges faced by rural health systems and the work being done to make beneficial changes.
As Lakewood now moves to the implementation phase, we wish them well, and hope they have the same feelings we have: renewed energy and belief that things can get better for patients and providers.
Summer 2022: MAPS Issues Statement on Patient Safety
The Minnesota Alliance for Patient Safety (MAPS) mission is “Safe Care. Everywhere.” MAPS works to achieve its mission by engaging a diverse stakeholder coalition that includes an engaged Board of Directors, committed volunteer leaders, dedicated staff, and members that broadly represent Minnesota's healthcare community and patient partners. MAPS focuses on educational programming, patient safety-inspired projects, patient and family engagement, and collaboration across all care settings. At MAPS we continue to dialogue together about what safe care means and how it can best be achieved.
MAPS leaders have been attentive to the well-publicized case of a former Vanderbilt University nurse who was charged with a crime for delivering the wrong medication to a patient who subsequently died. This case has many facets beyond what can be understood by the headlines, and we believe continued dialogue that emphasizes “lessons learned” is important not just for this case but for implications on safe care everywhere.
MAPS remains committed to promoting excellence in care, a component of which is embracing a culture where errors and near misses are reported and addressed in an appropriate and timely manner. We believe that safe care allows medical providers to work in settings where they are encouraged to bring their errors forward, where a culture of reporting mistakes is a top priority, and where medical professionals respond in ways focused on how to make each care setting a safer place and can speak up without fear of inappropriate repercussion. The details of any case involving a medical error can be unsettling. Safe care requires patients and families working together with medical professionals to ensure that communication and action regarding errors are responsive, transparent, and timely.
Since its establishment in 2000, MAPS has been a leading force in new standards around informed consent, medication safety, and Just Culture in Minnesota. Today, MAPS is not only expanding these efforts but tackling other emerging topics in patient safety, including patient and family engagement, diagnostic error, and transitions of care. Please contact us via our Executive Director, Heidi Holste at firstname.lastname@example.org to learn how to get involved in MAPS. Visit our website to learn more – www.mnpatientsafety.org.
Winter 2021: MAPS Hires New Executive Director accessible here.
MAPS Statewide Community Advisory Council Creates In-Person Care Partner accessible here.
SPRING 2019: Two new grant-funded safety improvement projects accessible here.
MARCH 2019: Annual Adverse Health Events Features Patient Story accessible here.
MAPS Welcomes Three New Board Directors accessible here.
October 25, 2018: Executive Director Announced accessible here.
March 20, 2018 accessible here.
March 13, 2018 accessible here.
February 28, 2018 accessible here.
May 24, 2017 accessible here.
April 3, 2017 accessible here.
January 19, 2017 accessible here.
November 14, 2016 accessible here.