Medical errors should be examined in the context of system failure to generate lasting opportunities for learning and improvement. This commentary discusses the AHRQ 2022 report entitled Diagnostic Errors in the Emergency Department: a Systematic Review and suggests a focus on care delivery processes over individuals, definitions, error rate review, and system design as noteworthy approaches to error reduction.

… of emergency medicine … Ann Emerg Med … Misdiagnosis of a neurologic emergency such as stroke can lead to serious morbidity or mortality. Using a large multi-state database, this study examined the … neurological event after ED discharge. Extrapolated to a national level, this translates to over 55,000 patients …

Delayed diagnosis of stroke can lead to preventable disability. This meta-analysis of diagnostic accuracy for cerebrovascular events in the emergency department found that overall 9% of strokes were misdiagnosed. The risk of misdiagnosis was higher if stroke symptoms were transient, nonspecific, or mild. The authors suggest that interventions to improve stroke diagnosis should focus on these specific disease presentations.

Classic studies of the epidemiology of adverse events in hospitalized patients have identified safety issues using retrospective chart review combined with trigger tools. This study examined this methodology to detect adverse events in emergency department patients and found good agreement between independent clinical reviewers regarding the presence of errors and adverse events.

This retrospective chart review study examined diagnostic errors in neurological cases in an emergency department. The most common sources of error were clinician knowledge gaps, which accounted for nearly half of all identified mistakes, and cognitive slips. Radiology resident misreads were also frequently implicated in missed diagnoses.

… of resident handoffs in the emergency department . A checklist improved handoff quality without increasing …