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Health care executives Susan L. Montminy and Marlene Icenhower discuss their article, “Solving a hidden challenge: 10 tips to reduce diagnostic error in the emergency department.” Susan and Marlene explore the complex, high-pressure nature of ED environments and the often-overlooked dangers of diagnostic error, which can result in severe injury or death. They offer 10 actionable strategies to improve diagnostic accuracy, such as using “working diagnoses,” implementing diagnostic timeouts, minimizing interruptions, and addressing cognitive biases. They emphasize the importance of fostering a collaborative team culture that normalizes diagnostic uncertainty and supports open communication to protect patients and support clinical decision-making.
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Transcript
Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome Susan L. Montminy and Marlene Icenhower. They are both health care executives, and today’s KevinMD article is “Solving a hidden challenge: 10 tips to reduce diagnostic error in the emergency department.” Susan, Marlene, welcome to the show.
Susan L. Montminy: Thank you, Kevin. We’re glad to be here. Thank you so much.
Kevin Pho: All right, so before we talk about the article, just brief introductions about what you do and who you are. So Susan, why don’t you go first?
Susan L. Montminy: Sure. Thank you. Well, I’m a nurse, and I have been for more than 30 years. As part of that, I also hold a doctorate in organizational change and leadership. I share that because, throughout that time, risk management and patient safety have always been a part of my job, even before it was a part of my actual formal job description.
Like many nurses, I began at the bedside in a hospital very traditionally and then moved more into management roles. That’s where I learned about the importance of teamwork, culture, and communication in patient safety. One of my management roles was as an employee health manager, and that’s when the factors of emotional and physical health of each individual on the care team became apparent to me as key.
I share all of that because these experiences combine to position me well to begin this formal phase of my career in risk management. Most of those years were spent in a large multi-hospital academic health care system with a level one trauma center, and that really afforded me the opportunity to work with extremely clinically complex cases. We were responsible for 24/7 support to our frontline providers, and I later came to be in my current position as director of risk management at an MPL company. Here is where I can share ideas—such as those in the KevinMD article about diagnostic risks in the ED—with a broader audience.
Kevin Pho: All right, and before we talk about the article, Marlene, just briefly introduce yourself and tell us a bit about your story.
Marlene Icenhower: Sure. I am currently a senior risk specialist at Curi, a medical malpractice insurance company. I work with our West Coast policyholders, helping them navigate some of the sometimes thorny issues that arise in their organizations.
Susan and I had different paths. I started my professional career as a nurse, like her, working at a teaching hospital. I spent a lot of time watching the constant cycling of residents, interns, and students through there, which exposed me to many mistakes—lots of potential liability—which piqued my interest in risk and liability. So, on something of a lark, I went to law school, worked my way through as a nurse, and when I graduated, I wanted to be a corporate lawyer. But, much to my dismay, my medical background pigeonholed me into medical malpractice. I took a job at a firm that turned out to be a really good fit for me in medical malpractice defense. For years, I tried cases in that arena and ended up here in risk management. Over time, I found that health care risk management really suits my skill set, so, as I said, I’m a risk specialist, and I work with policyholders.
Kevin Pho: Both of you wrote the KevinMD article “10 tips to reduce diagnostic error in the emergency department.” Susan, for those who didn’t get the chance to read that article, just tell us what it’s about.
Susan L. Montminy: Oh, sure. First of all, the format really focuses on 10 tips. We wanted to make it simple, a quick reference for organizations to use, to bring into their departments and ask, “Could this be a problem for us? Could these solutions work for us? How might we implement them?” We understand how busy and stretched-thin resources are in many organizations—for a myriad of reasons, which we could do a whole other podcast on. The 10 tips were intended to be straightforward and to help people focus on the areas most likely to lead to error, which in turn can lead to harm.
How did we decide on these tips? We do clinical claims analyses on problematic areas, and from that data, we glean information that helps us target solutions—really a “biggest bang for your buck” approach for those who don’t have time to focus on 40 different things. We focus on the most likely issues that lead to errors and therefore harm, not just to the patient but also to the patient’s loved ones and to the health care team. There is a tremendous emotional toll on everyone involved. Also, as an MPL employee, I know that if anyone out there has been through the claim process, it can be physically and emotionally exhausting.
Kevin Pho: Susan, to follow up, and before we go into tips, just give us a sense of the scope of diagnostic error in the emergency department. Do we have any numbers or data to show how big this problem is?
Susan L. Montminy: Yes. Let me start broadly by going back to 1999, because that was the groundwork for “To Err Is Human,” when it was first appreciated that 98,000 Americans were dying from medical error each year. That spurred the modern patient safety movement. But it wasn’t until 2015, when “Improving Diagnosis in Health Care” was introduced by the Institute of Medicine, that diagnostic error was highlighted as a leading cause of patient harm.
Another really important statistic, published later in the British Medical Journal, found that 795,000 Americans either die or become permanently disabled each year due to misdiagnosis. Finally, our own five-year look-back at data showed that diagnostic error contributed to 26 percent of our medical malpractice claims and accounted for 41 percent of the indemnity paid. Beyond our data, organizations like Leapfrog, The Joint Commission, and AHRQ are also prioritizing this issue. So, that’s why we said, “What can we offer from our own data and claims experience?” That led to our piece on ED diagnostic error.
Marlene Icenhower: I would add that we spend a lot of time talking to health care organizations and providers about medical error, risk, and claims. Often, they don’t have a good handle on what’s generating claims in their organization. They might point to things like falls or medication errors, because those events are very easy to see—they happen quickly and dramatically—so they’re easy to track, trend, and work on. But diagnostic error can be more insidious. Sometimes patients get lost to follow-up, and they don’t realize they’ve been misdiagnosed until years later, so that feedback loop isn’t closed. Diagnostic error is hard to spot, and that’s one of the reasons we wrote this paper: to bring this topic to the forefront, because it’s not the falls or medication errors driving claims; it’s often diagnostic error.
Kevin Pho: Marlene, give us a typical example of a diagnostic error in the emergency department that you’re finding through claims. What would that look like?
Marlene Icenhower: Many of our data show that a significant portion of these diagnostic error cases involve infection. A patient might come in with vague abdominal symptoms, but because of the patient’s age or because of cognitive (intuitive) bias, the right test isn’t ordered, or the right history and physical isn’t done. They might not gather enough information or might gather inappropriate information, and the patient leaves with a UTI diagnosis when it’s actually an abscess or something else. That’s the typical case we see in the ED.
Kevin Pho: And when you mentioned intuitive bias, Marlene, what exactly is that?
Marlene Icenhower: It’s also referred to as cognitive bias. Intuitive thinking plays a huge role in the diagnostic process, particularly in high-pressure environments like the ED, where clinicians often rely on shortcuts—heuristics—based on context or past experience. Diagnosticians often think in terms of probability. While this can be helpful for efficiency, these shortcuts (biases) don’t always serve them well. They happen subconsciously in an instant, so they can be hard to detect.
An example would be a younger patient coming in with rectal bleeding. Based on age and probability, a clinician wouldn’t automatically leap to colon cancer; they might quickly conclude it’s likely hemorrhoids. But that leap can lead to a missed diagnosis if they don’t investigate other possibilities.
Kevin Pho: Before I get back to Susan, I just want to close the loop about the emergency department setting. We always think of the ED as a high-pressure environment, and it seems to be getting worse with staff cuts and other challenges. In general, what are some reasons the ED is so prone to diagnostic error?
Marlene Icenhower: From my perspective, the ED is chaotic. In that environment, there’s high activity and frequent interruptions. Each interruption can create a chance for error—maybe a provider forgets to return a phone call, enter an order, or note something in a chart. So we’re always coaching organizations to look for ways to reduce distractions and interruptions, especially in areas like the ED.
Susan L. Montminy: It’s also that most of these patients are new to the clinician. It’s not like a physician who’s been seeing a patient for years and knows their history. You have to make a snap decision based on a blank slate and whatever data you have right there. In those several hours when someone is in the ED, their condition can change rapidly, and the physician needs to reassess continually before the patient leaves with a diagnosis and treatment.
Another common example from our data involves orthopedic situations, like missed fractures. Maybe the X-ray got a preliminary read, and that read was relied on for the diagnosis, and the subsequent final read showed something different. That’s a unique risk in an ED setting too.
Kevin Pho: Susan, your article focuses on ways to overcome these diagnostic errors. What are some of the main tips you can share with us?
Susan L. Montminy: I’ll build on what Marlene was talking about with bias. Let’s name it. Don’t be afraid of it. Ask, “Is bias at play here? These pieces of information aren’t making sense. Are we missing something?” Also, really feel comfortable with uncertainty.
Another tip is to think of diagnosis as a team sport, just like health care in general is a team sport. If the physician is puzzled or if a treatment started isn’t yielding the expected results, call a huddle. Get a few people together to discuss: “What am I missing here?” or “What are we overlooking?” Those are two big ones.
Marlene Icenhower: Yes, that “team sport” concept translates into what we call a “diagnostic timeout.” Similar to a surgical timeout, you want a structured pause to reflect coolly on the case. We also encourage building in triggers for that pause—return visits, requests for refills, symptoms that don’t get better—because those can signal that maybe the initial diagnosis was incorrect.
Kevin Pho: Marlene, what would that look like from a clinician’s standpoint? How do you implement a diagnostic timeout in a busy ED setting?
Marlene Icenhower: It’s very similar to a surgical timeout. For a puzzling case, where there’s a misalignment between symptoms and test results, or where something just isn’t clicking, gather the team—maybe by phone or in a quiet room—and go around asking, “Are we missing something?” You see this sometimes portrayed on TV shows like House, but it’s a real technique. You examine the full picture without distractions and have each person offer input.
And it’s important to identify triggers for this: a repeat visit, a treatment not working, an unexpected lab result. These things should prompt you to say, “Let’s step back and think this through again.”
Susan L. Montminy: I’d also add that we encourage reporting misdiagnoses as adverse events, investigating them the same way you would a fall or a medication error, so you can learn from them. Was it a communication gap, a technology gap, a process gap? Then you can modify your system accordingly.
For instance, the design of the electronic health record matters a lot if the ED physician depends on it for data review. Leaders can help by having IT specialists, quality specialists, and physicians collaborate: “Follow me around for a shift; see what my screen looks like. How can we make sure I see all the information at once? Could we use AI to integrate results faster?” Proactive system design can be extremely helpful.
Kevin Pho: Marlene, can you share a success story where you implemented these changes and really moved the needle in reducing diagnostic error?
Marlene Icenhower: Ideally, I’d like to see more stories where there’s an ambiguous diagnosis, the provider communicates that uncertainty, and other team members or disciplines gather to discuss what might be missing. Maybe someone picks up on a subtle cognitive bias and corrects the diagnosis. Then, afterward, the organization studies that “good catch” with a success analysis to see how teamwork averted harm, celebrating the things that went right.
We want to normalize uncertainty in diagnosis so that providers don’t feel pressured to express absolute certainty all the time. Communication, reflection, and structured processes can make a huge difference.
Kevin Pho: We’re talking to Susan Montminy and Marlene Icenhower. They are both health care executives, and today’s KevinMD article is “Solving a hidden challenge: 10 tips to reduce diagnostic error in the emergency department.” I’m going to end now with some take-home messages that you want to leave with the KevinMD audience. Susan, why don’t you go first?
Susan L. Montminy: Sure. Thank you. Really, take the 10 tips and have a conversation in your department. If you want to go further, there is a white paper associated with the article, and it has a self-assessment that you can bring into your emergency department to spot vulnerabilities. Compare our data to your own data, then focus your efforts. Diagnostic error harms so many people—patients, their loved ones, and the health care team—so it’s worth the time to drill down and prevent it.
Kevin Pho: And Marlene, we’ll end with you. What are your take-home messages?
Marlene Icenhower: I think I would tell folks that it’s perfectly fine to be unsure. Diagnosticians need to be comfortable with uncertainty and communicate that uncertainty to both their team and their patient. Also, be aware of cognitive or diagnostic bias and how it plays a role in diagnostic error.
Kevin Pho: Susan and Marlene, thank you so much for sharing your perspectives and insight, and thanks again for coming on the show.
Susan L. Montminy: Our pleasure.
Marlene Icenhower: Thanks, Kevin.