Exploring clinical lessons learned by experienced hospitalists from diagnostic errors and successes.

Susrutha Kotwal; Mason Howell; Laura Zwaan; Scott M Wright

Study

Exploring clinical lessons learned by experienced hospitalists from diagnostic errors and successes.

February 28, 2024

Kotwal S, Howell M, Zwaan L, et al. J Gen Intern Med. 2024;Epub Jan 26.

View more articles from the same authors.

Achieving diagnostic excellence is a primary focus in health care. In this qualitative study, researchers interviewed hospitalists at five hospitals to examine clinical lessons learned from diagnostic errors and successes. Five themes were identified: excellence in clinical reasoning as a core skill; elucidating insights from patients and other care team members; reflecting on the diagnostic process; commitment to a growth mindset; and prioritizing self-care and well-being.

PubMed citation

Available at

Related Resources From the Same Author(s)

Real-world virtual patient simulation to improve diagnostic performance through deliberate practice: a prospective quasi-experimental study.

December 15, 2021

Implementation of the I-PASS handoff program in diverse clinical environments: a multicenter prospective effectiveness implementation study.

November 16, 2022

What happens to the medication regimens of older adults during and after an acute hospitalization?

September 11, 2013

Morbidity and mortality conference, grand rounds, and the ACGME's core competencies.

October 25, 2006

Seroprevalence of SARS-CoV-2 among frontline health care personnel in a multistate hospital network--13 academic medical centers, April-June 2020.

September 23, 2020

Care transition of trauma patients: processes with articulation work before and after handoff.

February 16, 2022

Clinical communities at Johns Hopkins Medicine: an emerging approach to quality improvement.

September 2, 2015

Patient generated research priorities to improve diagnostic safety: a systematic prioritization exercise.

April 5, 2023

Improving diagnostic performance through feedback: the Diagnosis Learning Cycle.

September 1, 2021

Identifying and prioritizing educational content from a malpractice claims database for clinical reasoning education in the vocational training of general practitioners.

October 4, 2023

What can we learn from in-depth analysis of human errors resulting in diagnostic errors in the emergency department: an analysis of serious adverse event reports.

May 18, 2022

Associations between in-hospital mortality, health care utilization, and inpatient costs with the 2011 resident duty hour revision.

May 15, 2019

What has been the impact of Covid-19 on safety culture? A case study from a large metropolitan healthcare trust.

September 2, 2020

Determinants of burnout and other aspects of psychological well-being in healthcare workers during the Covid-19 pandemic: a multinational cross-sectional study.

May 5, 2021

Comparison of military and civilian methods for determining potentially preventable deaths: a systematic review.

May 23, 2018

Evaluation of effectiveness and safety of pharmacist independent prescribers in care homes: cluster randomised controlled trial.

March 1, 2023

Perceived bullying among internal medicine residents.

September 4, 2019

2019 update on medical overuse: a review.

September 25, 2019

Assessment of a simulated case-based measurement of physician diagnostic performance.

January 23, 2019

A systematic review of teamwork training interventions in medical student and resident education.

June 4, 2008

Think twice: effects on diagnostic accuracy of returning to the case to reflect upon the initial diagnosis.

September 23, 2020

Improving handoff by deliberate cognitive processing: results from a randomized controlled experimental study.

April 28, 2021

Advancing diagnostic safety research: results of a systematic research priority setting exercise.

February 24, 2021

Improving medical residents’ self-assessment of their diagnostic accuracy: does feedback help?

February 2, 2022

Effect on diagnostic accuracy of cognitive reasoning tools for the workplace setting: systematic review and meta-analysis.

September 14, 2022

Common contributing factors of diagnostic error: a retrospective analysis of 109 serious adverse event reports from Dutch hospitals.

August 23, 2023

The nature, causes, and clinical impact of errors in the clinical laboratory testing process leading to diagnostic error: a voluntary incident report analysis.

October 25, 2023

Do malpractice claim clinical case vignettes enhance diagnostic accuracy and acceptance in clinical reasoning education during GP training?

September 20, 2023

Impact of diagnostic checklists on the interpretation of normal and abnormal electrocardiograms.

May 31, 2023

Imagining the future of diagnostic performance feedback.

April 12, 2023

Is bias in the eye of the beholder? A vignette study to assess recognition of cognitive biases in clinical case workups.

February 17, 2016

The challenges in defining and measuring diagnostic error.

June 24, 2015

To what extent are adverse events found in patient records reported by patients and healthcare professionals via complaints, claims and incident reports?

January 30, 2005

Patient record review of the incidence, consequences, and causes of diagnostic adverse events.

July 7, 2010

Unit-based incident reporting and root cause analysis: variation at three hospital unit types.

August 17, 2016

Advancing the research agenda for diagnostic error reduction.

August 28, 2013

Does inappropriate selectivity in information use relate to diagnostic errors and patient harm? The diagnosis of patients with dyspnea.

August 7, 2013

Relating faults in diagnostic reasoning with diagnostic errors and patient harm.

February 8, 2012

The nature and causes of unintended events reported at 10 internal medicine departments.

November 23, 2011

Inpatient notes: reducing diagnostic error—a new horizon of opportunities for hospital medicine.

October 26, 2016

Diagnostic errors by medical students: results of a prospective qualitative study.

December 13, 2017

Analysis of unintended events in hospitals: inter-rater reliability of constructing causal trees and classifying root causes.

July 8, 2009

'Immunising' physicians against availability bias in diagnostic reasoning: a randomised controlled experiment.

March 18, 2020

The American College of Surgeons' closed claims study: new insights for improving care.

April 11, 2007

The impact of racism on child and adolescent health.

July 1, 2019

Adverse event reporting tool to standardize the reporting and tracking of adverse events during procedural sedation: a consensus document from the World SIVA International Sedation Task Force.

January 25, 2012

Caring for our own: deploying a systemwide second victim rapid response team.

April 28, 2010

Multistate point-prevalence survey of health care-associated infections.

April 9, 2014

Clinical data sharing improves quality measurement and patient safety.

March 24, 2021

Extended work shifts and neurobehavioral performance in resident-physicians.

March 10, 2021

Cumulative effect of flexible duty-hour policies on resident outcomes: long-term follow-up results from the FIRST trial.

July 15, 2020

Effect on patient safety of a resident physician schedule without 24-hour shifts.

July 15, 2020

The patient reporting and action for a safe environment (PRASE) intervention: a feasibility study.

December 21, 2016

Improving patient safety through the involvement of patients: development and evaluation of novel interventions to engage patients in preventing patient safety incidents and protecting them against unintended harm.

November 16, 2016

Can staff and patient perspectives on hospital safety predict harm-free care? An analysis of staff and patient survey data and routinely collected outcomes.

April 22, 2015

Effects on resident work hours, sleep duration and work experience in a Randomized Order Safety Trial Evaluating Resident-physician Schedules (ROSTERS).

June 26, 2019

What can patients tell us about the quality and safety of hospital care? Findings from a UK multicentre survey study.

March 28, 2018

Can patient involvement improve patient safety? A cluster randomised control trial of the Patient Reporting and Action for a Safe Environment (PRASE) intervention.

February 15, 2017

Exploring how ward staff engage with the implementation of a patient safety intervention: a UK-based qualitative process evaluation.

August 2, 2017

Patient safety, error reduction, and pediatric nurses' perceptions of smart pump technology.

May 7, 2014

The Charter on Professionalism for Health Care Organizations.

September 6, 2017

Exploring the causes of adverse events in hospitals and potential prevention strategies.

February 24, 2010

War games and diagnostic errors.

January 18, 2017

Can patient safety incident reports be used to compare hospital safety? Results from a quantitative analysis of the English National Reporting and Learning System data.

January 6, 2016

International recommendations for national patient safety incident reporting systems: an expert Delphi consensus-building process.

February 1, 2017

The Ask Me to Explain campaign: a 90-day intervention to promote patient and family involvement in care in a pediatric emergency department.

June 1, 2016

Reducing the burden of surgical harm: a systematic review of the interventions used to reduce adverse events in surgery.

February 26, 2014

The practice of respect in the ICU.

August 1, 2018

Development and evaluation of a required patient safety course.

September 3, 2008

April 27, 2022

Impact of performance and information feedback on medical interns' confidence-accuracy calibration.

April 3, 2024

Social aspects of clinical errors: a discussion paper.

March 25, 2009

Optimizing Pediatric Patient Safety in the Emergency Care Setting.

October 19, 2022

Accuracy of practitioner estimates of probability of diagnosis before and after testing.

May 5, 2021

Implementing a human factors approach to RCA(2) : tools, processes and strategies.

March 10, 2021

Understanding the "Swiss cheese model" and its application to patient safety.

July 21, 2021

Survey of nurses' experiences applying The Joint Commission's medication management titration standards.

November 3, 2021

The time is now: addressing implicit bias in obstetrics and gynecology education.

May 17, 2023

Association between end-of-rotation resident transition in care and mortality among hospitalized patients.

December 14, 2016

A partially structured postoperative handoff protocol improves communication in 2 mixed surgical intensive care units: findings from the Handoffs and Transitions in Critical Care (HATRICC) prospective cohort study.

February 6, 2019

Thirty-day outcomes support implementation of a surgical safety checklist.

January 9, 2013

Developing a standard handoff process for operating room–to-ICU transitions: multidisciplinary clinician perspectives from the Handoffs and Transitions in Critical Care (HATRICC) study.

August 1, 2018

Relationship between performance measurement and accreditation: implications for quality of care and patient safety.

November 2, 2005

Crowding in the Emergency Department: Challenges for the Care of Children.

March 15, 2023

Time of day effects on the incidence of anesthetic adverse events.

August 23, 2006

Personal formularies of primary care physicians across 4 health care systems.

August 4, 2021

Epidemiology of medication-related adverse events in nursing homes.

November 8, 2006

Information flow during pediatric trauma care transitions: things falling through the cracks.

September 11, 2019

Understanding preventable deaths in the geriatric trauma population: analysis of 3,452,339 patients from the Center of Medicare and Medicaid Services Database.

December 1, 2021

Widespread misinterpretation of advance directives and Portable Orders for Life-Sustaining Treatments threatens patient safety and causes undertreatment and overtreatment.

July 12, 2023

A qualitative study of systemic influences on paramedic decision making: care transitions and patient safety.

January 28, 2015

Threats to safety during sedation outside of the operating room and the death of Michael Jackson.

April 20, 2016

Are more experienced clinicians better able to tolerate uncertainty and manage risks? A vignette study of doctors in three NHS emergency departments in England.

February 27, 2019

Use of paediatric early warning systems in Great Britain: has there been a change of practice in the last 7 years?

February 26, 2014

Mortality risks associated with emergency admissions during weekends and public holidays: an analysis of electronic health records.

June 21, 2017

Medical misadventures as errors and mistakes and motor vehicular accidents in the disproportionate burden of childhood mortality among Blacks/African Americans in the United States: CDC Dataset, 1968-2015.

March 13, 2024

Development, testing, and findings of a pediatric-focused trigger tool to identify medication-related harm in US children's hospitals.

April 16, 2008

Adverse events in the neonatal intensive care unit: development, testing, and findings of an NICU-focused trigger tool to identify harm in North American NICUs.

October 25, 2006

A contemporary analysis of closed claims related to wrong site surgery.

March 29, 2023

An examination of factors that predict the perioperative culture of safety.

June 9, 2021

Related Resources

Impact of performance and information feedback on medical interns' confidence-accuracy calibration.

April 3, 2024

React, reframe and engage. Establishing a receiver mindset for more effective safety negotiations.

November 8, 2023

Middle manager responses to hospital co-workers' unprofessional behaviours within the context of a professional accountability culture change program: a qualitative analysis.

November 8, 2023

Associations between hospitalist shift busyness, diagnostic confidence, and resource utilization: a pilot study.

October 11, 2023

Strategies for Improving Clinician Psychological Safety in Reporting and Discussing Diagnostic Error.

September 27, 2023

Physician perspectives on responding to clinician-perpetuated interpersonal racism against Black patients with serious illness.

September 13, 2023

GoodDx.org

April 26, 2023

Imagining the future of diagnostic performance feedback.

April 12, 2023

Should audits consider the care pathway model? A new approach to benchmarking real-world activities.

September 19, 2022

Improving medication reconciliation in hospitals.

August 31, 2022

Patient Safety Innovations

A Virtual Hospitalist Program to Address a Hospital’s Challenges at the Start of the COVID-19 Pandemic

April 27, 2022

Patient Safety Innovations

The Michigan Hospital Medicine Safety Consortium (HMS) Finds Infectious Diseases (ID) Physician Approval for Placement of Peripherally Inserted Central Catheters (PICCs) Prevents Unnecessary PICC Use and Reduces Complications

February 23, 2022

Bridging the feedback gap: a sociotechnical approach to informing clinicians of patients' subsequent clinical course and outcomes.

June 30, 2021

A program to provide clinicians with feedback on their diagnostic performance in a learning health system.

October 28, 2020

Impact of an obstetrical hospitalist program on the safety events in a mid-sized obstetrical unit.

September 16, 2020

WebM&M Cases

Misdiagnosis of a Pelvic Mass versus Pregnancy

July 29, 2020

Direct observation of depression screening: identifying diagnostic error and improving accuracy through unannounced standardized patients.

May 1, 2020

A new approach of assessing patient safety aspects in routine practice using the example of "doctors handwritten prescriptions."

June 26, 2019

Adverse events and patient outcomes among hospitalized children cared for by general pediatricians vs hospitalists.

January 9, 2019

Perspective

The Comprehensivist Model of Care: A Hospitalist's View

November 1, 2018

Interview

In Conversation With… David Meltzer, MD, PhD

November 1, 2018

Association of hospitalist years of experience with mortality in the hospitalized Medicare population.

January 17, 2018

Inpatient notes: reducing diagnostic error—a new horizon of opportunities for hospital medicine.

October 26, 2016

Vital signs are still vital: instability on discharge and the risk of post-discharge adverse outcomes.

August 31, 2016

Do physicians clean their hands? Insights from a covert observational study.

July 27, 2016

Reviewing deaths in British and US hospitals: a study of two scales for assessing preventability.

July 20, 2016

Staying silent about safety issues: conceptualizing and measuring safety silence motives.

July 20, 2016

Interhospital transfer patients discharged by academic hospitalists and general internists: characteristics and outcomes.

January 6, 2016

Patient-initiated second opinions: systematic review of characteristics and impact on diagnosis, treatment, and satisfaction.

July 15, 2015

The effect of hospitalist discontinuity on adverse events.

March 25, 2015

See More About The Topic

Hospitals

Hospital Medicine

Clinical Misdiagnosis

Audit and Feedback

Hospitalists

Exploring clinical lessons learned by experienced hospitalists from diagnostic errors and successes.

A Virtual Hospitalist Program to Address a Hospital’s Challenges at the Start of the COVID-19 Pandemic

The Michigan Hospital Medicine Safety Consortium (HMS) Finds Infectious Diseases (ID) Physician Approval for Placement of Peripherally Inserted Central Catheters (PICCs) Prevents Unnecessary PICC Use and Reduces Complications

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Exploring clinical lessons learned by experienced hospitalists from diagnostic errors and successes.

A Virtual Hospitalist Program to Address a Hospital’s Challenges at the Start of the COVID-19 Pandemic

The Michigan Hospital Medicine Safety Consortium (HMS) Finds Infectious Diseases (ID) Physician Approval for Placement of Peripherally Inserted Central Catheters (PICCs) Prevents Unnecessary PICC Use and Reduces Complications

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site