The PSNet Collection

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

Raghuram N, Alodan K, Bartels U, et al. Virchows Archiv. 2021;478(6):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.

Maternal Safety

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.

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

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.

The Consequences of Miscommunication Regarding a Possible Artifact

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.

Unwell Women: Misdiagnosis and Myth in a Man-Made World.

Cleghorn E. New York, NY: Dutton; 2021. ISBN: 9780593182956.

Women have been affected by implicit bias that undermines the safety of their care and trust in the medical system. This book shares the history anchoring the mindsets driving ineffective care for women and a discussion of the author’s long-term lupus misdiagnosis.

Cancer diagnoses delayed among prisoners in Washington state.

Medscape Medical News. May 12, 2021.

Delays and mistakes in health care for distinct patient populations hold improvement lessons for the broader system. This news story highlights problems in correctional system cancer diagnoses and treatment that may indicate other types of prison care delivery problems.

Incidence, duration and risk factors associated with delayed and missed diagnostic opportunities related to tuberculosis: a population-based longitudinal study.

Miller AC, Arakkal AT, Koeneman S, et al. BMJ Open. 2021;11(2):e045605.

Delayed diagnosis is a critical patient safety concern. This cohort study, consisting of 3,500 patients with tuberculosis (TB) over a 17-year period, found that more than three-quarters of patients experienced at least one missed opportunity for a diagnosis in the year before they were finally diagnosed with TB. The average duration of the diagnostic delay was nearly 32 days. Missed opportunities occurred most commonly in outpatient settings. A previous WebM&M commentary discusses patient harm resulting from a missed TB diagnosis.

High delayed and missed injury rate after inter-hospital transfer of severely injured trauma patients.

Hensgens RL, El Moumni M, IJpma FFA, et al. Eur J Trauma Emerg Surg. 2020;46(6):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.

Risk of misdiagnosis and delayed diagnosis with COVID-19: a syndemic approach.

Muhrer JC. Nurs Pract. 2021;46(2):44-49.

The COVID-19 pandemic has led to wide-ranging changes to health care delivery, some of which may negatively impact patient outcomes.The authors use a syndemic perspective to discuss existing challenges interfering with diagnosis (structural, socioeconomic, patient-related, and provider-related), how the COVID-19 pandemic has exacerbated those challenges, and strategies related to nurse practitioners and community health workers to improve diagnosis.

Missed acute coronary syndrome during telephone triage at out-of-hours primary care: lessons from a case-control study.

Erkelens DC, Rutten FH, Wouters LT, et al. J Patient Saf. 2022;18(1):40-45.

Delays in diagnosis and treatment during after-hours care pose serious threats to patient safety. This case-control study compared missed acute coronary syndrome (ACS) cases to other cases with chest discomfort occurring during out-of-hours services in primary care. Predictors of missed ACS included the use of cardiovascular medication, non-retrosternal chest pain, and consultation of the supervising general practitioner.

Implicit bias in stroke care: a recurring old problem in the rising incidence of young stroke.

Bhat A, Mahajan V, Wolfe N. J Clin Neurosci. 2021;85(Mar):27-35.

Misdiagnosis, variation in treatment of stroke and gaps in secondary prevention in young patients can result in adverse outcomes. This article discusses the possible causes of implicit bias in stroke care in this population, the effects of bias on patient outcomes, and interventions to circumvent implicit bias.

The COVID-19 pandemic and dentistry: parts 1 and 2.

Coulthard P, Thomson P, Dave M, et al. Br Dent J. 2020;229:743-747; 801-805.

The COVID-19 pandemic suspended routine dental care. This two-part series discusses the clinical challenges facing the provision of routine dental care during the pandemic (Part 1) and the medical, legal, and economic consequences of withholding or delaying dental care (Part 2).

Identifying factors leading to harm in English general practices: a mixed-methods study based on patient experiences integrating structural equation modeling and qualitative content analysis.

Ricci-Cabello I, Gangannagaripalli J, Mounce LTA, et al. J Patient Saf. 2021;17(1):e20-e27.

Patient safety in primary care is an emerging focus. This cross-sectional study across primary care clinics in England explored the main factors contributing to patient-reported harm experiences. Factors included incidents related to communication, care coordination, and incorrect or delayed; diagnosis and/or treatment.

Delayed Breast Cancer Diagnosis: A False Sense of Security.

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.

Lifetime prevalence and correlates of patient-perceived medical errors experienced in the U.S. ambulatory setting: a population-based study.

Sundwall DN, Munger MA, Tak CR, et al. Health Equity. 2020;4(1):430-437.

This study surveyed 9,206 adults across the United States about their perceptions of medical errors occurring in ambulatory care settings. Thirty-six percent of respondents perceived that their doctor has ever made a mistake, provided an incorrect diagnosis, or given an incorrect (or delayed) treatment. According to these findings, patient-perceived medical errors and harms occurred most commonly in women and those in poor health with comorbid conditions.

Cancer diagnostic delay in Northern and Central Italy during the 2020 lockdown due to the coronavirus disease 2019 pandemic.

Ferrara G, De Vincentiis L, Ambrosini-Spaltro A, et al. Am J Clin Pathol. 2021;155(1):64-68.

The COVID-19 pandemic has led to patients delaying or forgoing necessary health care. Comparing the same 10-week period in 2018, 2019 and 2020, researchers used data from seven hospitals in northern-central Italy to assess the impact of COVID-19 on cancer diagnoses. Compared to prior years, cancer diagnoses overall fell by 45% in 2020. Researchers noted the largest decrease in cancer diagnoses among skin, colorectal, prostate, and bladder cancers.

L.A.’s poorest patients endure long delays to see medical specialists. Some die waiting.

Dolan J, Mejia B. Los Angeles Times. September 30, 2020.

Socioeconomic conditions influence access to health care, and as a result, reduce its safety and reliability. This story describes how inequity can affect the care of disadvantaged patient populations and shares data on wait times for specialty care in Los Angeles County that contributed to costly diagnostic and treatment delays.

Using telehealth to revolutionize the speed of making rare disease diagnoses.

Nothaft W, Moore G, Le Cam Y. Stat News. August 27, 2020.

Patients with rare diseases present diagnostic challenges. This article introduces the potential for improvements in diagnosis that telemedicine brings to the process through enabling access to appropriate expertise previously limited by geography.

Doctors turned my sister away; less than two years later she died of cervical cancer.

Harvey-Jenner C. Cosmopolitan. August 27, 2020.

Implicit biases are known to impact effective diagnosis. This story highlights how dismissed concerns resulted in a delay in cancer diagnosis that contributed to the death of a young woman.

Patient Safety.

Levett-Jones T, ed. Patient Safety. 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.

All Content

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

All Content

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Provide Feedback Anonymously

Submit Your Case

Continue as a Guest

Continue Logged In

Submit Your Case

Continue as a Guest

Already have a PSNet

Account?

New Users