• Patients identified diagnosis research priorities complementary to researchers.
• Patients prioritised research on care coordination, transitions and implicit bias.
• Findings can inform research funding to reduce diagnostic error.

Scalable solutions to enhance bedside diagnostic processes are needed, and these should target the most commonly misdiagnosed clinical presentations of key diseases causing serious harms. New studies should confirm overall rates are representative of current U.S.-based ED practice and focus on identified evidence gaps (errors among common diseases with lower-severity harms, paediatric ED errors and harms, dynamic systems factors such as overcrowding, and false positives).

Policy changes to consider based on this review include:

1. Standardising measurement and research results reporting to maximise comparability of measures of diagnostic error and misdiagnosis-related harms.
2. Creating a National Diagnostic Performance Dashboard to track performance
3. Using multiple policy levers (e.g., research funding, public accountability, payment reforms) to facilitate the rapid development and deployment of solutions to address this critically important patient safety concern.

Key findings from the report:

• There were 400 excess deaths attributable to pulmonary embolism misdiagnosis from March 2021 to April 2022 in England and Wales. 
• In parts of England and Wales the number of deaths due to pulmonary embolism were almost 3 times the national average.
• The clinical guidelines and diagnostic processes used in England and Wales are out of step with our European counterparts and, in Jenny’s case, were not used correctly. 
• Clinical teams too often lack the training, expertise and/or equipment to deliver safe and effective pulmonary embolism care. 

Commenting on the report, Tim Edwards said:

"My research found that there are hundreds of people who, like my mother Jenny, died from pulmonary embolism following misdiagnosis. It's vital we learn from these deaths, and the errors that have occurred, so we can take action to improve pulmonary embolism care. By publishing this report, I hope to start a dialogue that leads to positive change, so others do not suffer the loss of a loved one as we have."

Helen Hughes, Chief Executive of Patient Safety Learning said:

“This new report highlights serious patient safety concerns relating to the diagnosis of pulmonary embolisms. Urgent action is now needed to ensure that guidelines and diagnostic processes are up to date and that clinicians have the resources they need to deliver safe and effective care. It is also vital that we increase awareness of the key symptoms of pulmonary embolisms among both healthcare professionals and the wider public. Patient Safety Learning are proud to be supporting Tim and his campaign for improvement in pulmonary embolism care and to reduce avoidable deaths.”
 

Calls for action

The report includes nine calls for action to improve pulmonary embolism care:

1 Raise the level of suspicion for pulmonary embolism – given a surge in PE-related deaths, greater awareness amongst frontline emergency department and other clinicians of the importance of considering the possibility of PE during their diagnostic decision-making. More general training alongside specialisms and simulation to support practice and development of decision-making skills. Could the NEWS scoring system be calibrated to consider the aggregate of scores over a 5-6 hour period is one area for further discussion. 

2 Buy-in for clinical guidelines - clinical guidance is only as valuable as, firstly, its validity and there is evidence that the NHS is not applying pulmonary embolism guidance considered best practice in comparable European countries and, secondly, adherence, which is evidenced as inconsistent at best and worst, ignored. This report calls for a change, not just a review, of NICE clinical guideline NG158 covering pulmonary embolism diagnosis. 

3 Avoidance of high-risk appetite - to achieve operating standards and meet financial incentives, risk appetite should not be a variable that can be compromised or amended. A compliance metric tracking whether clinical guidelines were successfully followed could be included as a diagnostic tool used as part of the Get it Right First Time (GIRFT) initiative 8 to ensure CTPA scanning for pulmonary embolism is not under-used. 

4 Ensure radiology departments have the appropriate resources - so they can deliver a safe and effective service. Currently 41% of clinical radiologists do not have the right equipment 3 and the levels of scanners is less than half that in France and a quarter of that in Germany. There are also personnel shortages. There needs to be a plan in place to address these shortages. 

5 National consistency, compliance and risk management - exploration of the underlying causes of regional variation, whether from differentials in resources or processes. Ensure oversight approaches/audits are suitably embedded within existing clinical governance systems. 

6 Patient engagement - meaningful engagement with those affected when carrying out an incident investigation to ensure family members’ expertise is harnessed and that they are treated as partners in the learning response (where they so wish), not just in setting the terms of reference. 

7 Independence - while independent authors may contribute to investigations, independent subject-matter experts are not always involved therefore undermining the integrity of any report conclusions. NHS England’s 2015 Serious Incident Framework guidelines require independent contributors to ensure objectivity and so clearly there may need to be a review of how 'contributors' is defined and how this process may better ensure lessons are being suitably learnt. 

8 Knowledge sharing – effective, timely dissemination of learning from a serious incident investigation carried out in one organisation across the NHS to other organisations which may experience a similar type of PE misdiagnosis incident in the future. Ensure Clinical Knowledge Summaries providing the latest research and clinical findings are sufficiently disseminated and actioned by frontline emergency department and clinical staff in a timely fashion. 

9 Public awareness – extension of existing awareness campaign advising those at risk of the symptoms to look out for and when to seek medical attention

You can access the report in full via the attached PDF document below. 

Further reading

• House of Commons Debate - Pulmonary Embolisms: Diagnosis (30 November 2022)
• Royal College of Radiologists: Briefing for pulmonary embolism debate (November 2022)
• HSIB - Clinical decision making: diagnosis of pulmonary embolism in emergency departments (24 March 2022)

• Part I outlines ways to engage people in the organisation to ensure adequate resources to implement measurement and learning activities.
• Part II contains a self-assessment checklist to gauge readiness for implementation, as well as guidance for choosing a measurement strategy that fits with your organisation's resources.
• Part III describes four different strategies (systematic approaches to measurement) based on different types of data sources. Organisations are encouraged to use a strategy that fits with available data sources. Each strategy is outlined in step-by-step instructions for identifying potential diagnostic safety events. Case examples illustrate how organisations have used each strategy to learn about diagnostic safety in their facilities and practices.
• Part IV provides recommendations for systematically reviewing and analysing case data and translating findings into useful insights for learning and improvement. It also includes guidance for training reviewers and using structured case review tools.

Reaching 95%: decision support tools are the surest way to improve diagnosis now (5 October 2021)

1. Be The Expert On You - a patient-facing strategy that prepares patients and their families to tell their personal health stories in a clear, concise way.
2. 60 Seconds To Improve Diagnostic Safety - this prepares providers to practice deep and reflective listening for one minute at the start of a patient-encounter.

• White Paper: Implementing Closing the Loop Safe Practices for Diagnostic Results
• Close the Loop in Your Organization: A Step-by-Step Guide
• Safety Recommendations & Implementation Strategies: Closing the Loop
• Health IT Safe Practices for Closing the Loop Toolkit
• Closing the Loop: Evidence-based Literature Review
• Podcasts - Part 1: Diagnostic Error and the Importance of Closing the Loop, Part 2: Closing the Loop through Technology and Collaboration, Part 3: Closing the Loop Learning from the Data.