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Abdominal pain in the emergency department: missed diagnoses.

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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.

The influence of the availability heuristic on physicians in the emergency department.

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Ly DP. Ann Emerg Med. 2021;78:650-657.

A common type of diagnostic error is availability bias, or diagnosing a patient based on experiences with past similar cases. This study examined whether an emergency physician’s recent experience of a patient presenting with shortness of breath and diagnosed with pulmonary embolism increased subsequent pulmonary embolism diagnoses. While pulmonary embolism diagnosis did increase over the following ten days, that effect did not persist over the 50 days following the first 10 days.

Analyzing diagnostic errors in the acute setting: a process-driven approach.

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Griffin JA, Carr K, Bersani K, et al. Diagnosis (Berl). 2022;9:77-88.

Diagnostic errors in the acute care setting can result in increased morbidity and mortality. Using the Diagnostic Error Evaluation and Research (DEER) taxonomy, researchers reviewed 16 records of patients whose deaths were associated with at least one medical error. Most (81.3%) patients had at least one diagnostic error and a total of 113 failure points and 30 significant failure points.

Misdiagnosis of acute myocardial infarction: a systematic review of the literature.

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Kwok CS, Bennett S, Azam Z, et al. Crit Pathw Cardiol. 2021;20:155-162.

Misdiagnosis of cardiovascular conditions can lead to serious patient harm. This systematic review found that misdiagnosis of acute myocardial infarction (AMI) occurs in approximately 1-2% of cases, and AMI is commonly diagnosed as other heart conditions, musculoskeletal pain, or gastrointestinal disease. The authors suggest that there are opportunities to reduce cases of missed AMI with better education about atypical symptoms and improved training of electrocardiogram interpretation.

The Contribution of Diagnostic Errors to Maternal Morbidity and Mortality During and Immediately After Childbirth: State of the Science.

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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.

Safety events impacting hospitalized patients following motor vehicle crashes: a qualitative study of reports from Pennsylvania hospitals.

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Kukielka E. Patient Saf. 2021;3:18-27.

Trauma patients, who often suffer multiple, severe injuries and who may arrive to the Emergency Department (ED) unconscious, are vulnerable to adverse events. Using data reported to the Pennsylvania Patient Safety Reporting System (PA-PSRS), researchers in this study evaluated the safety challenges of caring for patients presenting to the ED after a motor vehicle collision. Common challenges included issues with monitoring, treatment, evaluation, and/or documentation, patient falls, medication errors, and problems with transfers.

Dangers of Missing an Epidural Abscess: Multiple Visits and Delayed Diagnosis with a Severely Negative Outcome

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September 29, 2021

A 44-year-old man presented to his primary care physician (PCP) with complaints of new onset headache, photophobia, and upper respiratory tract infections. He had a recent history of interferon treatment for Hepatitis C infection and a remote history of cervical spine surgery requiring permanent spinal hardware. On physical examination, his neck was tender, but he had no neurologic abnormalities. He was sent home from the clinic with advice to take over-the-counter analgesics.

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.

Clinical features and preventability of delayed diagnosis of pediatric appendicitis.

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Michelson KA, Reeves SD, Grubenhoff JA, et al. JAMA Netw Open. 2021;4:e2122248.

Diagnostic errors, including delayed diagnoses, continue to be a patient safety concern. This case-control study of children treated at five pediatric emergency departments explored the preventability of delayed diagnosis of pediatric appendicitis and associated outcomes. Researchers estimated that 23% of delayed diagnosis cases were likely to be preventable and that delayed diagnosis led to longer hospital length of stay, higher perforation rates, and additional surgical procedures.

Handshake antimicrobial stewardship as a model to recognize and prevent diagnostic errors

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September 29, 2021

The handshake antimicrobial stewardship program (HS-ASP) was developed and implemented at Children’s Hospital Colorado (CHCO). In 2014, the CHOC HS-ASP team began labeling specific interventions as “Great Catches” which were considered to have altered, or had the potential to alter, the patient’s trajectory of care. CHOC researchers used these "Great Catches" to identify potential diagnostic errors.

Bringing the clinical laboratory into the strategy to advance diagnostic excellence.

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Lubin IM, Astles J R, Shahangian S, et al. Diagnosis (Berl). 2021;8:281-294.

Diagnostic error reduction continues to be a patient safety focus. This article outlines innovative ways clinical laboratory professionals can support diagnostic excellence, such as improved communication between laboratory professionals, providers and patients.

Diagnostic discrepancies between antemortem clinical diagnosis and autopsy findings in pediatric cancer patients.

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Raghuram N, Alodan K, Bartels U, et al. Virchows Archiv. 2021;478:1179-1185.

Autopsies are an important tool for identifying diagnostic errors. This retrospective study of 821 pediatric cancer deaths found that 10% had a major diagnostic discrepancy between antemortem and postmortem diagnoses. These discrepancies primarily consisted of missed infections, missed cancer diagnoses, and organ complications.

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Burrus S, Hall M, Tooley E, et al. Pediatrics. 2021;148: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.

Curated Libraries

Maternal Safety

A system-wide hospital child maltreatment patient safety program.

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Hansen J, Terreros A, Sherman A, et al. Pediatrics. 2021;148: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.

Toolkit for Engaging Patients to Improve Diagnostic Safety.

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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.

Handshake antimicrobial stewardship as a model to recognize and prevent diagnostic errors.

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Searns JB, Williams MC, MacBrayne CE, et al. Diagnosis (Berl). 2021;8:347-352.

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.

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

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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.

The COVID trap: pediatric diagnostic errors in a pandemic world.

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Fatemi Y, Coffin SE. Diagnosis (Berl). 2021;8:525-531.

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.

Learning from patient safety incidents involving acutely sick adults in hospital assessment units in England and Wales: a mixed methods analysis for quality improvement.

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Urquhart A, Yardley S, Thomas E, et al. J R Soc Med. 2021;114:563-574.

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.

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