Understanding diagnostic processes in emergency departments: A mixed methods case study protocol

Michelle Daniel, Sunyoung Park, Colleen M. Seifert, P. Paul Chandanabhumma, Michael D. Fetters, Eric Wilson, Hardeep Singh, Kalyan Pasupathy, Prashant Mahajan

Research output: Contribution to journalArticlepeer-review


Introduction Diagnostic processes in the emergency department (ED) involve multiple interactions among individuals who interface with information systems to access and record information. A better understanding of diagnostic processes is needed to mitigate errors. This paper describes a study protocol to map diagnostic processes in the ED as a foundation for developing future error mitigation strategies. Methods and analysis This study of an adult and a paediatric academic ED uses a prospective mixed methods case study design informed by an ED-specific diagnostic decision-making model (the modified ED-National Academies of Sciences, Engineering and Medicine (NASEM) model) and two cognitive theories (dual process theory and distributed cognition). Data sources include audio recordings of patient and care team interactions, electronic health record data, observer field notes and stakeholder interviews. Multiple qualitative analysis methods will be used to explore diagnostic processes in situ, including systems information flow, human-human and human-system interactions and contextual factors influencing cognition. The study has three parts. Part 1 involves prospective field observations of patients with undifferentiated symptoms at high risk for diagnostic error, where each patient is followed throughout the entire care delivery process. Part 2 involves observing individual care team providers over a 4-hour window to capture their diagnostic workflow, team coordination and communication across multiple patients. Part 3 uses interviews with key stakeholders to understand different perspectives on the diagnostic process, as well as perceived strengths and vulnerabilities, in order to enrich the ED-NASEM diagnostic model. Ethics and dissemination The University of Michigan Institutional Review Board approved this study, HUM00156261. This foundational work will help identify strengths and vulnerabilities in diagnostic processes. Further, it will inform the future development and testing of patient, provider and systems-level interventions for mitigating error and improving patient safety in these and other EDs. The work will be disseminated through journal publications and presentations at national and international meetings.

Original languageEnglish (US)
Article numbere044194
JournalBMJ open
Issue number9
StatePublished - Sep 24 2021


  • accident & emergency medicine
  • health & safety
  • paediatric A&E and ambulatory care
  • qualitative research
  • risk management

ASJC Scopus subject areas

  • Medicine(all)


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