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Improving Care to Reduce Stroke Misdiagnosis

We will partner with patients and families to deliver accurate, timely diagnoses that enable prompt, correct treatments, avoiding misdiagnosis-related harms. Even one patient harmed by preventable diagnostic error is too many.

— Dr. Newman-Toker

The center’s first signature initiative will be to tackle stroke misdiagnosis throughout Johns Hopkins Hospital emergency departments. Future initiatives will address sepsis and cancer diagnosis. Together, the initiatives will address the “big three” that account for at least one-third of all diagnostic errors and likely more than half of the harms from diagnostic errors.

Why Stroke Misdiagnosis?

  • More than 1 million people in the United States suffer a stroke or transient ischemic attack (TIA, or pre-stroke) every year, with about three in four being first-time strokes.
  • Stroke is the fifth leading cause of death in the United States, killing nearly 130,000 people a year, or one every 4 minutes. That’s one in every 20 deaths.
  • Stroke is a leading cause of long-term disability and among the most preventable. Rapid access to treatment reduces brain injury, prevents complications, avoids major stroke after minor stroke and improves patient outcomes.
  • Minor, early strokes are currently missed 30 to 50 percent of the time, often when patients have common symptoms — dizziness, vertigo, headaches — that are diagnosed as a less serious problem.
  • Timely diagnosis leading to prompt, correct treatments can prevent death and disability.

Currently, a lack of prompt treatment leads to preventable harms because patients suffer major strokes after undiagnosed minor strokes. Our target is to cut harms from missed strokes in half within five years.

How will we accomplish this?

We will take a multi-pronged implementation approach:

  • Training: We will train providers in the latest bedside diagnostic techniques using state-of-the art educational simulations. These will include screen-based case simulations for cognitive skills as well as novel partial task trainers for psychomotor skills. Our simulations will be driven by real-world data from our ongoing AVERT clinical trial (Clinical NCT02483429).
  • Teamwork: We will launch the Comprehensive Unit-based Safety Program to Improve Diagnosis (CUSPID). This adapted version of the highly successful culture change framework known as CUSP will specifically target achieving diagnostic excellence through local, grass-roots efforts that identify diagnostic error problems, determine causes and envision solutions.
  • Technology: We will apply cutting edge technologies to enhance early stroke recognition in the Johns Hopkins Health System’s emergency departments. Portable diagnostic devices will facilitate the use of telemedicine to deliver immediate expertise to the bedside. Automation of this process, currently underway in our AVERT clinical trial (Clinical NCT02483429), will further enhance accuracy and efficiency. These projects will increase quality and decrease costs.
  • Tuning: We will develop operational measures of diagnostic accuracy, error and value for stroke. Our first-generation Diagnostic Performance Dashboard will monitor harms from missed stroke and process failures, enabling feedback to providers and ensuring accountability at all levels. We will conduct economic analyses of stroke interventions, identifying the highest value solutions.
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