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Halsey-Nichols M, McCoin N. Emerg Med Clin North Am. 2021;39:703-717.
Diagnostic errors among patients presenting to the emergency department (ED) with abdominal pain are common. This article summarizes the factors associated with missed diagnoses of abdominal pain in the ED, the types of abdominal pain that are commonly misdiagnosed, and recommended steps for discharging a patient with abdominal pain without a final diagnosis.

Bajaj K, de Roche A, Goffman D. Rockville, MD: Agency for Healthcare Research and Quality; September 2021. AHRQ Publication No. 20(21)-0040-6-EF.

Maternal safety is threatened by systemic biases, care complexities, and diagnostic issues. This issue brief explores the role of diagnostic error in maternal morbidity and mortality, the preventability of common problems such as maternal hemorrhage, and the importance of multidisciplinary efforts to realize improvement. The brief focuses on events occurring during childbirth and up to a week postpartum. This issue brief is part of a series on diagnostic safety.
Driessen RGH, Latten BGH, Bergmans DCJJ, et al. Virchows Arch. 2020;478:1173-1178.
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.
Nikouline A, Quirion A, Jung JJ, et al. CJEM. 2021;23:537–546.
Trauma resuscitation is a complex, specialized care process with a high risk for errors. This systematic review identified 39 unique errors occurring in trauma resuscitation involving emergency medical services (EMS) handover; airway management; inadequate assessment and/or management of injuries; inadequate monitoring, transfusion/blood-related errors; team communication errors; procedure-related errors; or errors in disposition.

Constellation, Society to Improve Diagnosis in Medicine. 

The processes supporting safe and accurate diagnosis involve many steps that are prone to human error. This collaborative will engage teams to explore test result management and follow-up coordination to improve timeliness, collaboration, and communication to support safe care. The launch of the collaborative has been delayed due to COVID-19.
Hensgens RL, El Moumni M, IJpma FFA, et al. Eur J Trauma Emerg Surg. 2020;46:1367-1374.
Missed injuries and delayed diagnoses are an ongoing problem in trauma care. This cohort study conducted at a large trauma center found that inter-hospital transfer of severely injured patients increases the risk of delayed detection of injuries. For half of these patients, the new diagnoses led to a change in treatment course. These findings highlight the importance of clinician vigilance when assessing trauma patients.
Gleason KT, Harkless G, Stanley J, et al. Nurs Outlook. 2021;69:362-369.
To reduce diagnostic errors, the National Academy of Medicine (NAM) recommends increasing nursing engagement in the diagnostic process. This article reviews the current state of diagnostic education in nursing training and suggests inter-professional individual and team-based competencies to improve diagnostic safety.

The Leapfrog Group.

Examination of diagnostic failure and identification of reduction strategies require multidisciplinary expertise to be successful. This collaborative initiative will initially develop educational materials to inform health care organization adoption of diagnostic improvement best practices. Building on that experience, a survey component to complement the Leapfrog annual survey will be developed to enhance measurement and motivate improvement.

After a failed induction at 36 weeks, a 26-year-old woman underwent cesarean delivery which was complicated by significant postpartum hemorrhage. The next day, the patient complained of severe perineal and abdominal pain, which the obstetric team attributed to prolonged pushing during labor. The team was primarily concerned about hypotension, which was thought to be due to hypovolemia from peri-operative blood loss. After several hours, the patient was transferred to the medical intensive care unit (ICU) with persistent hypotension and severe abdominal and perineal pain. She underwent surge

Washington DC; National Quality Forum: October 6, 2020.

With input from a stakeholder committee, the National Quality Forum identified recommendations for the practical application of the Diagnostic Process and Outcomes domain of the 2017 Measurement Framework  for measuring and improving diagnostic error and patient safety. The committee developed four ‘use cases’ (missed subtle clinical findings; communication failures; information overload; and dismissed patients) reflecting high priority examples of diagnostic error that can result in patient harm. The report includes comprehensive, broad-scope, actionable, and specific recommendations for implementing quality improvement activities to engage patients, educate clinicians, leverage technology, and support a culture of safety with the goal of reducing diagnostic errors. 
Stark N, Kerrissey M, Grade M, et al. West J Emerg Med. 2020;21:1095-1101.
This article describes the development and implementation of a digital tool to centralize and standardize COVID-19-related resources for use in the emergency department (ED). Clinician feedback suggests confirms that the tool has affected their management of COVID-19 patients. The tool was found to be easily adaptable to accommodate rapidly evolving guidance and enable organizational capacity for improvisation and resiliency.  
Cantey C. J Nurs Pract. 2020;16:582-585.
This article discusses cognitive decision processes and biases, and their consequences on clinical decision making by nurse practitioners. The authors present several clinical examples of diagnostic error and discuss strategies to avoid future errors.

Organisation for Economic Co-operation and Development.

Organizations worldwide are focusing efforts on reducing the conditions that contribute to medical error. This website provides a collection of reports and other resources that cover activities and concerns of the 37 member countries active in the organization to address universal challenges to patient safety.

Chicago, IL; Society to Improve Diagnosis in Medicine: August 2020. 

Patients and families provide unique insights for leaders working to improve diagnosis. This report highlights how organizations can best implement patient advisory council programs to spark learning, enhance feedback, and support a safety culture that enhances the impact of those efforts. 

Chicago, IL; Society to Improve Diagnosis in Medicine: August 2020.   

Patient and Family Advisory Councils (PFACs) are an established strategy that provides structure to a health care organization’s patient and family engagement efforts. This report shares insights and tools to establish a PFAC and engage them in diagnostic error reduction.      

Levett-Jones T, ed. Clin Sim Nurs. 2020;44(1):1-78; 2020;45(1):1-60.

Simulation is a recognized technique to educate and plan to improve care processes and safety. This pair of special issues highlights the use of simulation in nursing and its value in work such as communication enhancement, minority population care, and patient deterioration.   
Restrepo D, Armstrong KA, Metlay JP. Ann Intern Med. 2020;172:747-751.
Using two case examples, this article discusses how the influences of cognitive biases in clinical decision-making contribute to diagnostic error and steps in the diagnostic process to avoid such errors, including using diagnostic checklists, conferring with teammates or peers, and continuously reassessing treatment response.
Plint AC, Stang A, Newton AS, et al. BMJ Qual Saf. 2021;30:216-227.
This article describes emergency department (ED)-related adverse events in pediatric patients presenting to the ED at a pediatric hospital in Canada over a one-year period.  Among 1,319 patients at 3-months follow-up, 33 patients (2.5%) reported an adverse event related to their ED care.  The majority of these events (88%) were preventable. Most of the events involved diagnostic (45.5%) or management issues (51.5%) and resulted in symptoms lasting more than one day (72.7%).
Sacco AY, Self QR, Worswick EL, et al. J Patient Saf. 2021;17:e1759-e1773.
Using the IOM definition of diagnostic error, this study interviewed hospitalized adults to characterize their experiences with diagnostic errors and their perspectives on causes, impacts and prevention strategies. Nearly 40% of patients interviewed reported at least one diagnostic error in the past 5 years that adversely impacted their emotional and physical well-being. Qualitative analysis revealed five main themes underlying the causes of diagnostic error: problems with clinical evaluation, limited time with clinicians, poor communication between clinicians and patients or between clinicians, and systems failures. Suggested strategies to reduce diagnostic error included improvements to clinical management, increase patient access to clinicians, communication improvements between patients and clinicians and between clinicians, and self-advocacy by patients.