The PSNet Collection: All Content

The AHRQ PSNet Collection comprises an extensive selection of resources relevant to the patient safety community. These resources come in a variety of formats, including literature, research, tools, and Web sites. Resources are identified using the National Library of Medicine’s Medline database, various news and content aggregators, and the expertise of the AHRQ PSNet editorial and technical teams.

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Diagnostic Errors Case Studies

January 19, 2023

The Primary-Care Research in Diagnosis Errors (PRIDE) Learning Network was a Boston-based national effort to improve diagnostic safety. Hosted by the State of Massachusetts’ Betsy Lehman Center, it was led by the Harvard Brigham and Women’s Center for Patient Safety Research and Practice with funding from the Gordon and Betty Moore Foundation. ...

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

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Tougas C, Brimmo O. Pediatr Ann. 2022;51:e357-e363.

Diagnostic errors involving pediatric musculoskeletal radiographs can lead to adverse patient safety outcomes. This article discusses contributing factors to missed or delayed diagnosis of pediatric fractures and strategies to improve diagnosis.

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

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Ivanovic V, Assadsangabi R, Hacein-Bey L, et al. Clin Radiol. 2022;77:607-612.

Radiological interpretation errors can result in unnecessary additional tests, wrong treatment and delayed diagnosis. This study explored the correlation between neuroradiologists’ diagnostic errors and attendance at institutional tumor boards. Results show that higher attendance at tumor boards was strongly correlated with lower diagnostic error rates. The researchers recommend increased and continuous attendance at tumor boards for all neuroradiologists.

An evolution of reporting: identifying the missing link.

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

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.

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

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Li W, Stimec J, Camp M, et al. J Emerg Med. 2022;62:524-533.

While pediatric musculoskeletal radiograph misinterpretations are rare, it is important to know what features of the image area are associated with false-positive or false-negative diagnoses. In this study, pediatric emergency medicine physicians were asked to interpret radiographs with and without known fractures. False-positive diagnosis (i.e., a fracture was identified when there was none) were reviewed by an expert panel to identify the location and anatomy most prone to misdiagnosis.

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

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Alexander R, Waite S, Bruno MA, et al. Radiology. 2022:212631.

To reduce medical errors caused by fatigue, the Accreditation Council for Graduate Medical Education (ACGME) adopted duty hour restrictions for ACGME-accredited residency programs; however, other healthcare fields have not yet done so. This review presents the limited existing evidence for regulating duty hours for radiologists and proposes that additional research needs to be completed before implementing restrictions.

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

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Branch F, Santana I, Hegdé J. Diagnostics (Basel). 2022;12:105.

Anchoring bias is relying on initial diagnostic impression despite subsequent information to the contrary. In this study, radiologists were asked to read a mammogram and were told a random number which researchers claimed was the probability the mammogram was positive for breast cancer. Radiologists' estimation of breast cancer reflected the random number they were given prior to viewing the image; however, when they were not given a prior estimation, radiologists were highly accurate in diagnosing breast cancer.

Oncologic errors in diagnostic radiology: a 10-year analysis based on medical malpractice claims.

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Rosenkrantz AB, Siegal D, Skillings JA, et al. J Am Coll Radiol. 2021;18:1310-1316.

Prior research found that cancer, infections, and vascular events (the “big three”) account for nearly half of all serious misdiagnosis-related harm identified in malpractice claims. This retrospective analysis of malpractice claims data from 2008 to 2017 found that oncology-related errors represented the largest source of radiology malpractice cases with diagnostic allegations. Imaging misinterpretation was the primary contributing factor.

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

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Kim S, Goelz L, Münn F, et al. BMC Musculoskelet Disord. 2021;22:589.

Late diagnosis of upper extremity fractures can lead to delays in treatment. When two radiologists reviewed whole-body CT scans, each missed known fractures and identified previously unknown fractures. Slice thickness was not significantly associated with missed fractures; however, missed and late diagnosis occurred more often between the hours of 5pm and 1am.

Coming up for Err – Missed Diagnosis in a Patient with Recurrent Pneumothorax

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WebM&M Case August 25, 2021

A 31-year-old woman presented to the ED with worsening shortness of breath and was unexpectedly found to have a moderate-sized left pneumothorax, which was treated via a thoracostomy tube. After additional work-up and computed tomography (CT) imaging, she was told that she had some blebs and mild emphysema, but was discharged without any specific follow-up instructions except to see her primary care physician.

Racial disparities in diagnostic delay among women with breast cancer.

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Miller-Kleinhenz JM, Collin LJ, Seidel R, et al. J Am Coll Radiol. 2021;18:1384-1393.

Delayed diagnosis and treatment of breast cancer can lead to poor outcomes. Based on multi-year data from one health system, the authors of this cohort study found that black women with screen-detected breast cancers were more likely than white women to experience diagnostic delays, including delays in diagnostic evaluation and biopsy. The delay in diagnosis was also associated with an increase in breast cancer mortality.

Visual illusions in radiology: untrue perceptions in medical images and their implications for diagnostic accuracy.

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Alexander RG, Yazdanie F, Waite S, et al. Front Neurosci. 2021;15:629469.

Incorrect interpretation of radiologic images can result in delayed diagnosis or unneeded additional tests and treatment. This commentary describes the visual illusions radiologists use in detecting and categorizing abnormalities, and recommends further research into the ways visual illusions are used in order to improve diagnostic safety.

Breast cancer screening and overdiagnosis.

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Bulliard J‐L, Beau A‐B, Njor S, et al. Int J Cancer. 2021;149:846-853.

Overdiagnosis of breast cancer and the resulting overtreatment can cause physical, emotional, and financial harm to patients. Analysis of observational data and modelling indicates overdiagnosis accounts for less than 10% of invasive breast cancer in patients aged 50-69. Understanding rates of overdiagnosis can assist in ascertaining the net benefit of breast cancer screening.

Unlocking Solutions in Imaging: Working Together to Learn from Failings in the NHS.

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London, UK: Parliamentary and Health Service Ombudsman; 2021. ISBN 9781528627016.

Lack of appropriate follow up of diagnostic imaging can result in care delays, patient harm, and death. This report summarizes an investigation of 25 imaging failures in the British National Health Service (NHS). The analysis identified communication and coordination issues resulting in lack of action and reporting of unanticipated findings to properly advance care. Recommendations to improve imaging in the NHS include use of previous analyses to enhance learning from failure.

Errors in breast imaging: how to reduce errors and promote a safety environment.

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Sivarajah R, Dinh ML, Chetlen A. J Breast Imaging. 2021;3:221-230.

This article describes the Yorkshire contributory factors framework, which identifies factors contributing to safety errors across four hierarchical levels (active errors, situational factors, local working conditions, and latent factors) and two cross-cutting factors (communication systems and safety culture). The authors apply this framework to a case of missed mass on breast imaging and discuss how its use can help health systems effectively learn from error and develop systematic, proactive programs to improve safety and manage safety issues.

The Consequences of Miscommunication Regarding a Possible Artifact

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WebM&M Case June 30, 2021

A 52-year-old man complaining of intermittent left shoulder pain for several years was diagnosed with a rotator cuff injury and underwent left shoulder surgery. The patient received a routine follow-up X-ray four months later.

AI for radiographic COVID-19 detection selects shortcuts over signal.

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DeGrave AJ, Janizek JD, Lee S-I. Nat Mach Intell. 2021;3:610–619.

Artificial intelligence (AI) systems can support diagnostic decision-making. This study evaluates diagnostic “shortcuts” learned by AI systems in detecting COVID-19 in chest radiographs. Results reveal a need for better training data, improved choice in the prediction task, and external validation of the AI system prior to dissemination and implementations in different hospitals.

Machine learning is booming in medicine. It’s also facing a credibility crisis.

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Ross C. STAT. June 2, 2021.

Artificial intelligence and machine learning are often promoted as tools with impressive potential for generating rapid improvements in healthcare decision making. This news story highlights how underlying problems and testing failures limit the trustworthiness of conclusions drawn by the systems.

Ethical challenges in child abuse: what is the harm of a misdiagnosis?

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Brown SD. Pediatr Radiol. 2021;51:1070-1075.

Misdiagnosis of child abuse has far-reaching implications. This commentary discusses the ethical tensions faced by pediatric radiologists of both over- and under-diagnosing child abuse. The author suggests ways that physicians and professional societies can partner with legal advocates to create a more balanced pool of experts to alleviate perceptions of bias and acknowledge harms of misdiagnosed child abuse.

Delayed Breast Cancer Diagnosis: A False Sense of Security.

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WebM&M Case December 23, 2020

After a breast mass was identified by a physician assistant during a routine visit, a 60-year-old woman received a diagnostic mammogram and ultrasound. The radiology assessment was challenging due to dense breast tissue and ultimately interpreted as “probably benign” findings. When the patient returned for follow-up 5 months later, the mass had increased in size and she was referred for a biopsy.

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