This case involves a 2-year-old girl with acute myelogenous leukemia and thrombocytopenia (platelet count 26,000 per microliter) who underwent implantation of a central venous catheter with a subcutaneous port. The anesthetist asked the surgeon to order a platelet transfusion to increase the child’s platelet count to above 50,000 per microliter. In the post-anesthesia care unit, the patient’s arterial blood pressure started fluctuating and she developed cardiac arrest.
The Revised Safer Dx Instrument provides a standardized list of questions to help users retrospectively identify and assess the likelihood of a missed diagnosis in a healthcare episode. Results of the assessment are intended for use in system-level safety improvement efforts, clinician feedback, and patient safety research.
The instrument consists of a series of questions that address five aspects of the diagnostic process: (1) the patient-provider encounter (history, physical examination, ordering tests/referrals based on assessment); (2) performance and interpretation of diagnostic tests; (3) follow-up and tracking of diagnostic information over time; (4) subspecialty and referral-specific factors; and (5) patient-related factors.1 To answer the questions, the evaluator collects data from comprehensive electronic health records including information on a patient’s medical history, examination information, diagnostic test interpretation, and follow-up testing and diagnostic assessment. If the assessment indicates there was a likely diagnostic error (defined as a missed opportunity in diagnosis), users have the option to complete an additional process breakdown assessment as a guide designed to help identify factors contributing to the potential missed opportunity.
The original tool, the Safer Dx Instrument, was validated in a primary care setting, and results were published in 2016. In this study, the instrument yielded overall accuracy of 84%.2 A study published in 2017 on use of the tool in a pediatric intensive care unit found the tool had inter-rater agreement of 93.6% (k, 0.72).3 The project team made minor revisions to the original tool to address feedback from the pilot studies, as well as from several national experts. Since the release of the revised iteration of the tool (i.e., the Revised Safer Dx Instrument), use of condition-specific adaptations of the tool (e.g., Safer Stroke Dx) have found it to yield accurate results.4,5
For the best results, the project team suggests having multiple reviewers complete the assessment and discuss findings. Additionally, sites that wish to implement the tool may benefit from an existing safety environment that is supportive, with elements such as a patient safety culture, existing safety programs, and adequate staffing resources to implement the tool, including a multidisciplinary team with a dedicated safety analyst.
Institute for Safe Medication Practices
Articles contained in this library reflect the impact of the pandemic on patient harm in the acute care setting.
Washington, DC: United States Government Accountability Office; November 30, 2021. Publication GAO-22-105142.
Croke L. Guideline for prevention of unintentionally retained surgical items. AORN J. 2021;114(6):4-6. doi:
The medication-use process is highly complex with many steps and risk points for error, and those errors are a key target for improving safety. This Library reflects a curated selection of PSNet content focused on medication and drug errors. Included resources explore understanding harms from preventable medication use, medication safety improvement strategies, and resources for design.
This piece discusses patient safety challenges that arose as a result of the unique care circumstances surrounding the COVID-19 pandemic, particularly at the height of the pandemic in 2020.
Newcastle upon Tyne, UK: Care Quality Commission; September 2021.
Patient Safety Organizations (PSOs) are organizations dedicated to improving patient safety and healthcare quality that serve to collect and analyze data voluntarily reported by healthcare providers to promote learning.
Institute for Healthcare Improvement. March 15 - April 26, 2022.
Wiig S, Haraldseid-Driftland C, Tvete Zachrisen R, et al. J Patient Saf. 2021;17(8):e1707-e1718.