Finding Ways to Avoid Diagnostic Errors

KPSOM student presents quality-improvement study at national conference

October 19, 2023

KPSOM student Noah Contreras at the Society to Improve Diagnosis in Medicine conference.

KPSOM student Noah Contreras at the Society to Improve Diagnosis in Medicine conference.

Kaiser Permanente Bernard J. Tyson School of Medicine student Noah Contreras recently presented an original research project at the 16th Annual Society to Improve Diagnosis in Medicine (SIDM) national conference in Cleveland. 

The project, “An e-Biopsy Hybrid Review of Premature Coronary Artery Disease to Improve Diagnostic Accuracy,” focused on understanding diagnostic errors in patients with premature coronary artery disease (premCAD), identifying areas where evidence-based care can be more reliably provided to those patients, and developing ways to improve diagnostic timeliness and accuracy. Contreras joined the study with KPSOM faculty members Michael Kanter, MD, Ali Ghobadi, MD, Kerry Litman, MD, as well as Maverick Au, a Kaiser Permanente quality consultant.  

Dr. Ghobadi, also serves as the Assistant Physician Lead for the Kaiser Permanente eAutopsy/eBiopsy program, which researches systemic opportunities to improve patient care and reduce diagnostic errors in the Kaiser Permanent system. Ghobadi said he became aware of Contreras’ interest in researching diagnostic improvements while serving as one of the student’s Phase 1 instructors and working on previous projects with him.

“Noah made outstanding contributions to this work by participating in discussion and analysis of the results and synthesizing the outcomes to create and refine the poster which he presented at SIDM,” Ghobadi said. “This was as an excellent opportunity for Noah to critically evaluate a clinical study on improving diagnostic accuracy in premature CAD, and to present these findings at a national conference of renowned healthcare leaders. I believe this experience will serve to be extremely valuable in Noah’s development as a physician and clinical researcher, and he did an exceptional job with this project. Diagnostic errors are a leading issue in patient safety, and there is ongoing work in Kaiser Permanente with opportunities for more interested students to participate.”

KPSOM Faculty member Dr. Ali Ghobadi.

KPSOM Faculty member Dr. Ali Ghobadi.

SIDM is dedicated to research to identify ways to eliminate harm from diagnostic error through education, research, practice improvement, and patient engagement. Contreras shared his thoughts about the research project shortly after returning from the event. 

On his interest in quality improvement research:

I first became involved in the realm of Quality Improvement (QI) research during my time as an Academic Research Associate in the UCSF Fresno Emergency Department. Though I was not privy to the term “QI” at the time, looking back, all the clinical research we did focused on improving the quality of care of patients [who] presented to the Emergency Department. Those experiences laid the foundation for my knowledge of quality improvement and drove my desire to engage in more of that style [of] work upon entering medical school. 

On joining the project:

“Throughout my first year of medical school, I developed a fascination with cardiac conditions in Emergency Medicine settings. One of my Scientific Basis of Health small group facilitators and now close mentor, Dr. Ali Ghobadi, an emergency medicine physician and Associate Professor in the Department of Clinical Science, caught wind of this interest and asked me if I’d be interested in joining the project team. During the process of preparing for the conference, it was wonderful getting to work with familiar faces, such as Dr. Michael H. Kanter, Chair of Clinical Science and revered figure in the realm of QI, as well as Dr. Kerry Litman, family medicine physician and Associate Professor of Clinical Science, with whom I’ve had the pleasure of working on Narrative Medicine projects with before. I also got to learn from and work alongside new team members, such as Mimi Hugh and Laura Tuchman, who are the Director and a consultant, respectively, of Southern California Permanente Medical Group Performance Assessment. The team brought me in with open arms and were quick to onboard me and answer questions I had throughout the process.”

On why diagnostic errors happen:

Providers don’t intend to make mistakes; they don’t intend to misdiagnose. But they are human, and they are fallible, so there needs to be concrete systems in place that aid physicians in mitigating these errors. Unfortunately, often, these errors are often only able to be identified, like in the case of this project, in hindsight. Even in an integrated health system where medical records are easily accessible and workflows can be standardized and automated, there is still room for cracks to form that prevent timely patient diagnosis and adequate treatment. In the case of this study, which focuses on premature coronary artery disease (premCAD), underlying risk factors such as hypertension, obesity, and diabetes mellitus were being underdiagnosed or inadequately treated at a rate much higher than I expected. This concerns me for patients who aren’t in an integrated healthcare system, whose labs and notes don’t transfer as [easily] between providers as they do at Kaiser Permanente. Fortunately, through this study and the vast infrastructure provided by the greater Kaiser Permanente network, we were able to, alongside the Kaiser Permanente New Member Onboarding Team and Kaiser Permanente Electronic Health Record management team, identify and implement systems-level changes that are target aimed at mitigating these errors. What was also neat about being at this conference was seeing many of the topics we discuss in our Health Systems Science (HSS) curriculum come to life. Even in my early stage of medical education and systems-level-thinking training, I was well-equipped to follow along with presentations given by recipients of SIDM grant-funded projects and breakout session facilitators.

On the impacts of QI research:

I’m hopeful that this work will result in tangible changes for patients not only in the Kaiser Permanente system, but patients across and within all health systems. If you look at the changes that were made from a result of this – expanding New Member Onboarding practices, automating repeat labs for diabetic patients with abnormal labs, and enhancing the Kaiser Permanente atherosclerotic cardiovascular disease (ASCVD) Risk Estimator – you’ll notice that, though these changes came from a project based on premCAD, none of these changes are hyper-specific to premCAD. The risk factors for premCAD targeted here are common risk factors for both cardiovascular diseases and for conditions across the board. This means that patients with other medical history and underlying conditions stand to benefit from the system-level changes derived from this project.

While further analysis needs to be done to understand what impact these changes will have, they will no doubt be profound. Additionally, I anticipate that other health systems will see the work we did and be inspired to analyze their own systems and see what changes can be made to reduce diagnostic errors. I believe that quality improvement work is a cornerstone of health equity and the advancement of health justice, and I’m glad to have been able to contribute to this.