An evolution of reporting: identifying the missing link.

Sara Harsini; Salar Tofighi; Liesl Eibschutz; Brian Quinn; Ali Gholamrezanezhad

Commentary

An evolution of reporting: identifying the missing link.

August 10, 2022

Harsini S, Tofighi S, Eibschutz L, et al. Diagnostics (Basel). 2022;12(7):1761.

View more articles from the same authors.

Incomplete or delayed communication of imaging results can result in harm to the patient and have legal ramifications for the providers involved. This commentary presents a closed-loop communication model for the ordering clinician and radiologist. The model suggests the ordering clinician categorize the radiology report as “concordant” or “discordant”, and if discordant, provide an explanation.

PubMed citation

Available at

Free full text

Related Resources From the Same Author(s)

Medication errors in intensive care units: an umbrella review of control measures.

August 17, 2022

Medical malpractice lawsuits involving trainees in obstetrics and gynecology in the USA.

September 21, 2022

Biasing influence of 'mental shortcuts' on diagnostic decision-making: radiologists can overlook breast cancer in mamograms when prior diagnostic information is available.

March 30, 2022

Investigation of mental and physical health of nurses associated with errors in clinical practice.

October 26, 2022

How timely is diagnosis of lung cancer? Cohort study of individuals with lung cancer presenting in ambulatory care in the United States.

January 11, 2023

Healthcare-associated adverse events in alternate level of care patients awaiting long-term care in hospital.

September 14, 2022

Medicines reconciliation in the emergency department: important prescribing discrepancies between the shared medication record and patients' actual use of medication.

March 16, 2022

Communication on safe caregiving between community nurse case managers and family caregivers.

April 7, 2021

Can the standard configuration of a cardiac monitor lead to medical errors under a stress induction?

July 27, 2022

Preventable adverse events in obstetrics: systemic assessment of their incidence and linked risk factors.

February 16, 2022

The secondary use of data to support medication safety in the hospital setting: a systematic review and narrative synthesis.

February 23, 2022

In the eye of the storm: the role of the pharmacist in medication safety during the COVID-19 pandemic at an urban teaching hospital.

December 23, 2020

Assessment of the use of patient vital sign data for preventing misidentification and medical errors.

January 25, 2023

Missing diagnoses during the COVID-19 pandemic: a year in review.

June 23, 2021

Artificial intelligence for identifying the prevention of medication incidents causing serious or moderate harm: an analysis using incident reporters' views.

November 24, 2021

Comparison of a voluntary safety reporting system to a global trigger tool for identifying adverse events in an oncology population.

August 3, 2022

Surgery is in itself a risk factor for the patient.

June 1, 2022

Prolonged diagnostic intervals as marker of missed diagnostic opportunities in bladder and kidney cancer patients with alarm features: a longitudinal linked data study.

February 17, 2021

Implementation of an online reporting system to identify unprofessional behaviors and mistreatment directed at trainees at an academic medical center.

December 21, 2022

Hospital-acquired functional decline and clinical outcomes in older cardiac surgical patients: a multicenter prospective cohort study.

March 2, 2022

Patients who die by suicide: a study of treatment patterns and patient safety incidents in Norway.

November 9, 2022

Effectiveness of communication interventions in obstetrics--a systematic review.

April 21, 2021

Differences in hospitals' workplace violence incident reporting practices: a mixed methods study.

May 18, 2022

Benefits of reporting and analyzing nursing students' near-miss medication incidents.

March 9, 2022

Communication disparities between nursing home team members.

July 20, 2022

National statutory reporting: not even ticking the boxes? The quality of 'Learning from Deaths' reporting in quality accounts within the NHS in England 2017-2020.

March 1, 2023

Compensation claims in Danish emergency care: identifying hot spots and blind spots in the quality of care.

May 11, 2022

Contributors to diagnostic error or delay in the acute care setting: a survey of clinical stakeholders.

October 12, 2022

Gender bias in risk management reports involving physicians in training - a retrospective qualitative study.

November 9, 2022

Using community detection techniques to identify themes in COVID-19-related patient safety event reports.

December 7, 2022

How physicians think: a case-based diagnostic simulation exercise.

September 16, 2020

The impact of meaningful use and electronic health records on hospital patient safety.

November 2, 2022

May 4, 2022

An evidence and consensus-based definition of second victim: a strategic topic in healthcare quality, patient safety, person-centeredness and human resource management.

February 15, 2023

Critical care teamwork in the future: the role of TeamSTEPPS in the COVID-19 pandemic and implications for the future.

March 15, 2023

The e-Autopsy/e-Biopsy: a systematic chart review to increase safety and diagnostic accuracy.

October 26, 2022

Does racism impact healthcare quality? Perspectives of Black and Hispanic/Latino patients.

June 29, 2022

The effect of providing staff training and enhanced support to care homes on care processes, safety climate and avoidable harms: evaluation of a care home quality improvement programme in England.

August 18, 2021

Intraoperative sentinel events in the era of surgical safety checklists: results of a national survey.

March 3, 2021

To what extent is the World Health Organization's Medication Safety Challenge being addressed in English hospital organizations? A descriptive study.

February 16, 2022

Detection of missed fractures of hand and forearm in whole-body CT in a blinded reassessment.

September 29, 2021

Hospital inpatient falls across clinical departments.

September 1, 2021

Monitoring preventable adverse events and near misses: number and type identified differ depending on method used.

June 29, 2022

Use of e-triggers to identify diagnostic errors in the paediatric ED.

April 6, 2022

Diagnostic challenges in primary care: identifying and avoiding cognitive bias.

June 29, 2022

2020 Pennsylvania Patient Safety Reporting: an analysis of serious events and incidents from the nation’s largest event reporting database.

May 19, 2021

Harnessing event report data to identify diagnostic error during the COVID-19 pandemic.

December 15, 2021

The relationship of medical assistants' work engagement with their concerns of having made an important medical error: a cross-sectional study.

July 13, 2022

Identifying boundary spanning reporter roles in patient safety events.

August 24, 2022

Incidence, duration and risk factors associated with delayed and missed diagnostic opportunities related to tuberculosis: a population-based longitudinal study.

March 24, 2021

Avoiding a Med-Wreck: a structured medication reconciliation framework and standardized auditing tool utilized to optimize patient safety and reallocate hospital resources.

March 3, 2021

Interprofessional model on speaking up behaviour in healthcare professionals: a qualitative study.

May 25, 2022

Safety in fragile, conflict-affected, and vulnerable settings: An evidence scanning approach for identifying patient safety interventions.

March 30, 2022

Mitigating racial bias in machine learning.

June 22, 2022

Individualized medication review in older people with multimorbidity: a comparative analysis between patients living at home and in a nursing home.

May 25, 2022

Occurrence of no-harm incidents and adverse events in hospitalized patients with ischemic stroke or TIA: a cohort study using trigger tool methodology.

April 20, 2022

Development, pilot study, and psychometric analysis of the AHRQ Surveys on Patient Safety Culture (SOPS) Workplace Safety Supplemental Items for Hospitals.

June 29, 2022

Hospital-wide cardiac arrest in situ simulation to identify and mitigate latent safety threats.

June 8, 2022

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

Support opportunities for second victims lessons learned: a qualitative study of the top 20 US News and World Report Honor Roll Hospitals.

January 19, 2022

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

May 1, 2020

Interprofessional and intraprofessional communication about older people's medications across transitions of care.

May 26, 2021

Inviting patients to identify diagnostic concerns through structured evaluation of their online visit notes.

April 13, 2022

Trust and medical AI: the challenges we face and the expertise needed to overcome them.

April 21, 2021

Variation in the reporting of elective surgeries and its influence on patient safety indicators.

July 6, 2022

Using smart IV infusion pumps outside of patient rooms.

February 2, 2022

Identifying and reconciling patients' allergy information within the electronic health record.

July 6, 2022

Fostering a just culture in healthcare organizations: experiences in practice.

August 31, 2022

Filling a gap in safety metrics: development of a patient-centred framework to identify and categorise patient-reported breakdowns related to the diagnostic process in ambulatory care.

October 27, 2021

Pediatric transport safety collaborative: adverse events with parental presence during pediatric critical care transport.

November 10, 2021

Checklists to reduce diagnostic error: a systematic review of the literature using a human factors framework.

June 1, 2022

Role of the regulator in enabling a just culture: a qualitative study in mental health and hospital care.

August 10, 2022

The Diagnostic Error Index: a quality improvement initiative to identify and measure diagnostic errors.

February 10, 2021

Chief resident indirect supervision in training safety study: is a chief resident general surgery service safe for patients?

September 1, 2021

Patient race and opioid misuse history influence provider risk perceptions for future opioid-related problems.

November 4, 2020

Linking patient safety climate with missed nursing care in labor and delivery units: findings from the LaborRNs survey.

April 12, 2023

Promoting the psychological well-being of healthcare providers facing the burden of adverse events: a systematic review of second victim support resources.

June 23, 2021

Nonpunitive medication error reporting: 3-year findings from one hospital's primum non nocere initiative.

August 30, 2006

Family safety reporting in hospitalized children with medical complexity.

July 20, 2022

Patients' willingness and ability to identify and respond to errors in their personal health records: mixed methods analysis of cross-sectional survey data.

July 27, 2022

Patient outcomes after opioid dose reduction among patients with chronic opioid therapy.

January 12, 2022

Prevalence of undiagnosed diabetes identified by a novel electronic medical record diabetes screening program in an urban emergency department in the US.

February 22, 2023

Self-assessment and learning motivation in the second victim phenomenon.

February 1, 2023

A national study links nurses' physical and mental health to medical errors and perceived worksite wellness.

March 21, 2018

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

December 15, 2021

Neuroradiology diagnostic errors at a tertiary academic centre: effect of participation in tumour boards and physician experience.

August 17, 2022

Analysis of results from event investigations in industrial and patient safety contexts.

April 7, 2021

Diagnostic trajectories in primary care at 12 months: an observational cohort study.

June 15, 2022

Show me the money, I'll show you my complications: impacts of incentivized incident self-reporting among surgeons.

March 2, 2022

Identifying trigger concepts to screen emergency department visits for diagnostic errors.

December 16, 2020

Reported clinical incidents of children with intellectual disability: a qualitative analysis.

June 15, 2022

Diagnostic error in the pediatric hospital: a narrative review.

February 9, 2022

Feasibility of patient-reported diagnostic errors following emergency department discharge: a pilot study.

October 28, 2020

Exploration of prescribing error reporting across primary care: a qualitative study.

April 13, 2022

Identifying electronic medication administration record (eMAR) usability issues from patient safety event reports.

November 3, 2021

Telemedicine as a medical examination tool during the Covid-19 emergency: the experience of the onco-haematology center of Tor Vergata Hospital in Rome.

December 23, 2020

Inpatient telemedicine and new models of care during COVID-19: hospital design strategies to enhance patient and staff safety.

September 15, 2021

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

September 2, 2020

Dying for Care.

March 30, 2022

Increasing physician reporting of diagnostic learning opportunities.

December 23, 2020

Related Resources

Perspective

Artificial Intelligence and Patient Safety: Promise and Challenges

March 27, 2024

Interview

In Conversation with...Patrick Tighe about Artificial Intelligence

March 27, 2024

MRI safety: prepare for new guidance.

January 10, 2024

Psychological safety as a new ACGME requirement: a comprehensive all-in-one guide to radiology residency programs.

November 8, 2023

WebM&M Cases

“Copy and Paste” Notes and Autopopulated Text in the Electronic Health Records

October 31, 2023

Radiologist age and diagnostic errors.

October 18, 2023

Cross-Check QA: a quality assurance workflow to prevent missed diagnoses by alerting inadvertent discordance between the radiologist and AI in the interpretation of high acuity CT scans.

October 4, 2023

Factors associated with neuroradiologic diagnostic errors at a large tertiary-care academic medical center: a case-control study.

September 20, 2023

Radiographers' experience of preventing patient safety incidents in the context of radiological examinations.

September 13, 2023

Perceptions of radiation safety culture in medical imaging by role.

August 23, 2023

Patient Safety Innovations

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

July 31, 2023

Developing electronic clinical quality measures to assess the cancer diagnostic process.

June 21, 2023

WebM&M Cases

Critical Echocardiogram Result Lost to Follow-up.

June 14, 2023

Reducing errors resulting from commonly missed chest radiography findings.

May 31, 2023

Danger in discharge summaries: abbreviations create confusion for both author and recipient.

May 31, 2023

Diagnostic errors in musculoskeletal oncology and possible mitigation strategies.

May 24, 2023

Racism and electronic health records (EHRs): perspectives for research and practice.

April 12, 2023

Quality and safety: learning from the past and (re)imagining the future.

March 29, 2023

Common and consequential fractures that should not be missed in children.

November 30, 2022

Patient Safety Innovations

Journal Article

Study

Catching those who fall through the cracks: integrating a follow-up process for emergency department patients with incidental radiologic findings.

November 16, 2022

A longitudinal evaluation of computed tomography radiation incidents within a multisite NHS trust.

November 9, 2022

Prevalence and sources of duplicate information in the electronic medical record.

October 12, 2022

Inaccurate penicillin allergy labeling, the electronic health record, and adverse outcomes of care.

August 24, 2022

Development and pilot evaluation of an electronic health record usability and safety self-assessment tool.

August 24, 2022

Neuroradiology diagnostic errors at a tertiary academic centre: effect of participation in tumour boards and physician experience.

August 17, 2022

Pediatric musculoskeletal radiographs: anatomy and fractures prone to diagnostic error among emergency physicians.

August 3, 2022

WebM&M Cases

Medication Safety Events Related to Diagnostic Imaging

July 8, 2022

Mandating limits on workload, duty, and speed in radiology.

July 6, 2022

Preventing delayed and missed care by applying artificial intelligence to trigger radiology imaging follow-up.

March 30, 2022

Collaborative case review: a systems-based approach to patient safety event investigation and analysis.

March 30, 2022

See More About The Topic

Hospitals

Ambulatory Clinic or Office

Health Care Providers

Information Professionals

Radiology

An evolution of reporting: identifying the missing link.

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

Catching those who fall through the cracks: integrating a follow-up process for emergency department patients with incidental radiologic findings.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

An evolution of reporting: identifying the missing link.

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

Catching those who fall through the cracks: integrating a follow-up process for emergency department patients with incidental radiologic findings.

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