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Burrus S, Hall M, Tooley E, et al. Pediatrics. 2021;148(3):e2020030346.
Based on analysis of four years of data submitted to the Child Health Patient Safety Organization (CHILDPSO), researchers sought to identify types of serious safety events and contributing factors. Three main groups of serious safety events were identified: patient care management, procedural errors, and product or device errors. Contributing factors included lack of situational awareness, process failures, and failure to communicate effectively.
van der Zanden M, de Kok L, Nelen WLDM, et al. Diagnosis (Berl). 2021;8(3):333-339.
Endometriosis is a common clinical condition that is often subject to missed or delayed diagnosis. This qualitative study explored patients’ perspectives on the diagnostic process of endometriosis. Findings suggest that the diagnosis of endometriosis is hindered by delayed consultation, inadequate understanding and appraisal of symptoms by general practitioners, and inadequate communication between patients and providers.

Ensuring maternal safety is a patient safety priority. This library reflects a curated selection of PSNet content focused on improving maternal safety. Included resources explore strategies with the potential to improve maternal care delivery and outcomes, such as high reliability, care standardization, teamwork, unit-based safety initiatives, and trigger tools.

Rockville, MD: Agency for Healthcare Research and Quality; August 2021. AHRQ Publication No. 21-0047-2-EF.

Patient and family engagement is core to effective and safe diagnosis. This new toolkit from the Agency for Healthcare Research and Quality promotes two strategies to promote meaningful engagement and communication with patients to improve diagnostic safety: (1) a patient note sheet to help patients share their story and symptoms and (2) orientation steps to support clinicians listening and “presence” during care encounters.
Hansen J, Terreros A, Sherman A, et al. Pediatrics. 2021;148(3):e2021050555.
Physicians have demonstrated knowledge gaps in accurately diagnosing child maltreatment. This article describes the implementation of a system-wide daily review of patients with concerns of maltreatment, allowing child abuse pediatricians (CAPs) to intervene and address potential errors (e.g., history taking, injury identification, testing for occult injuries, and cognitive analysis) and to identify patients who require immediate intervention. Over a 30-month period, the program identified potential diagnostic errors and safe discharge concerns, many of which led to new or changed diagnoses.
Searns JB, Williams MC, MacBrayne CE, et al. Diagnosis (Berl). 2021;8(3):347-352.
This study leveraged “Great Catches” as part of an existing handshake antimicrobial stewardship program (HS-ASP) to identify potential diagnostic errors. Using a validated tool, researchers found that 12% of “Great Catch” cases involved diagnostic error. These cases included a diagnostic recommendation from the HS-ASP team (e.g., recommendations to consider alternative diagnoses, request additional testing, or additional interpretation of laboratory results). As these diagnostic recommendations often flagged diagnostic errors, this suggests that the HS-ASP model can be leveraged to identify and intervene on diagnostic errors in real time.
Dave N, Bui S, Morgan C, et al. BMJ Qual Saf. 2021;Epub Aug 20.
This systematic review provides an update to McDonald et al’s 2013 review of strategies to reduce diagnostic error.  Technique (e.g., changes in equipment) and technology-based (e.g. trigger tools) interventions were the most studied intervention types. Future research on educational and personnel changes would be useful to determine the value of these types of interventions.
Fernandez Branson C, Williams M, Chan TM, et al. BMJ Qual Saf. 2021;Epub Jul 27.
Receiving feedback from colleagues may improve clinicians’ diagnostic reasoning skills. By building on existing models such as Safer Dx, and collaborating with professionals outside of the healthcare field, researchers developed the Diagnosis Learning Cycle, a model intended to improve diagnosis through peer feedback.

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.

Fatemi Y, Coffin SE. Diagnosis (Berl). 2021;Epub Aug 5.
Using case studies, this commentary describes how availability bias, diagnostic momentum, and premature closure resulted in delayed diagnosis for three pediatric patients first diagnosed with COVID-19. The authors highlight cognitive and systems factors that influenced this diagnostic error.
Urquhart A, Yardley S, Thomas E, et al. J R Soc Med. 2021;Epub Aug 4.
This mixed-methods study analyzed patient safety incident reports between 2005-2015 to characterize the most frequently reported incidents resulting in severe harm or death in acute medical units. Of the 377 included reports, diagnostic errors, medication-related errors, and failure to monitor patient incidents were most common. Patients were at highest risk during handoffs and transitions of care. Lack of active decision-making during admission and communication failures were the most common contributors to incidents.
Vaghani V, Wei L, Mushtaq U, et al. J Am Med Inform Assoc. 2021;Epub Jul 20.
Based on the SaferDx and SPADE frameworks, researchers applied a symptom-disease pair-based electronic trigger (e-trigger) to identify patients hospitalized for stroke who had been previously discharged from the emergency department with a diagnosis of headache or dizziness in the preceding 30 days. Analyses show that the e-trigger identified missed diagnoses of stroke with a modest positive predictive value.

Kahneman D, Sibony O, Sunstein CR. London, UK: William Collins; 2021. ISBN 9780008472566.

Lack of agreement, or noise, in leadership and clinical decision making can contribute to poor care. This book discusses influences on human judgement that contribute to disagreement when different people receive the same information and how to prevent its negative impact. It describes the influence of noise in a variety of sectors including medicine with specific emphasis on diagnosis.
Miller-Kleinhenz JM, Collin LJ, Seidel R, et al. J Am Coll Radiol. 2021;Epub Jul 16.
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.

Houston, TX:  Baylor College of Medicine.

This Center represents a partnership with the Veterans Affairs Health Services Research & Development Center of Innovation to enhance researchers' skills through active participation in diagnostic safety research and policy development. The goals of the program include a focus on behavioral health interventions and measurement.
Driessen RGH, Latten BGH, Bergmans DCJJ, et al. Virchows Arch. 2020;478(6):1173-1178.
Autopsies are an important tool for detecting misdiagnoses. Autopsies were performed on 32 septic individuals who died within 48 hours of admission to the intensive care unit. Of those, four patients were found to have class I missed major diagnosis. These results underscore the need to perform autopsies to improve diagnosis.

James Augustine, MD, is the National Director of Prehospital Strategy at US Acute Care Solutions where he provides service as a Fire EMS Medical Director. We spoke with him about threats and concerns for patient safety for EMS when responding to a 911 call.

Betsy Lehman Center for Patient Safety.

Case analysis provides important opportunities to highlight factors that culminate in diagnostic error. This website supports learning generated from the Primary-Care Research in Diagnosis Errors, or PRIDE, Learning Network. The effort examines de-identified error cases and shares collective assessments to support improvement.