Understanding human causes of diagnostic errors can lead to more specific targeted, specific recommendations and interventions. Using three classification instruments, researchers examined a series of serious adverse events related to diagnostic errors in the emergency department. Most of the human errors were based on intended actions and could be classified as mistakes or violations. Errors were more frequently made during the assessment and testing phases of the diagnostic process.
Fortman E, Hettinger AZ, Howe JL, et al. J Am Med Inform Asso. 2020.
Physicians from different health systems using two computerized provider order entry (CPOE) systems participated in simulated patient scenarios using eye movement recordings to determine whether the physician looked at patient-identifying information when placing orders. The rate of patient identification overall was 62%, but the rate varied by CPOE system. An expert panel identified three potential reasons for this variation – visual clutter and information density, the number of charts open at any given time, and the importance placed on patient identification verification by institutions.
Schnapp BH, Sun JE, Kim JL, et al. Diagnosis (Berl). 2018;5:135-142.
In 2015, the National Academy of Medicine called for renewed focus on reducing diagnostic error. Among patients admitted to the hospital shortly after discharge home from the emergency department, researchers found that 19% of cases involved a cognitive error, such as faulty information processing or inaccurate data verification, which may contribute to diagnostic errors.
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