Lin Y-K, Lin C-J, Chan H-M, et al. Injury. 2014;45:83-7.
Full-time trauma surgeons had a lower incidence of diagnostic errors (defined as the incidence of missed injuries in severely injured patients) compared with surgeons who primarily practiced in other specialties, according to this retrospective analysis of patients admitted to a Taiwanese surgical intensive care unit.
Smits M, Groenewegen PP, Timmermans DRM, et al. BMC Emerg Med. 2009;9:16.
Emergency department (ED) patients are particularly vulnerable to adverse events, and a prior study of closed malpractice claims implicated systems factors such as poor teamwork in adverse patient outcomes. This study used root cause analysis of incident reports to identify the types and causes of errors and unanticipated events in the ED. Incidents included poor communication and teamwork, particularly with other departments, but medication errors and diagnostic errors were also noted. The authors recommend that organizations integrate the ED into hospital-wide safety improvement efforts.
Griffey RT, Bohan JS. Qual Saf Health Care. 2006;15:344-6.
This study found that other health care providers were a relatively frequent source of complaints for the emergency department, and the issues they raised could be used to identify opportunities to improve quality and safety.
Masoudi FA, Magid DJ, Vinson DR, et al. Circulation. 2006;114:1565-71.
The investigators studied medical records of heart attack victims and found that 12% did not have their tests interpreted correctly in the emergency room and did not receive appropriate care for acute myocardial infarction.
Kachalia A, Gandhi TK, Puopolo AL, et al. Ann Emerg Med. 2007;49:196-205.
This study addressing the causes of missed and delayed diagnoses in emergency department patients used similar methodology as a companion study of error in the ambulatory setting and a prior study of surgical patients. Errors involved a broad range of patients and conditions. As in the outpatient arena, errors generally occurred due to failure to order diagnostic tests or interpret them correctly; factors contributing to error included cognitive factors (ie, physician judgment or knowledge), but system factors (ie, fatigue or communication breakdowns) were involved in a significant proportion of cases. As was also found in the study of ambulatory patients, the multifactorial nature of the errors identifies many potential areas for action but likely defies simple solutions.
Sung S, Forman-Hoffman V, Wilson MC, et al. J Gen Intern Med. 2006;21:1075-8.
The investigators surveyed primary care physicians regarding direct notification of results for three specific diagnostic tests. They found that physicians generally favored direct reporting to patients when test results were normal, had less diagnostic severity, or had less potential for emotional impact.
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