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Politi RE, Mills PD, Zubkoff L, et al. J Patient Saf. 2022;Epub Apr 30.
Delays in diagnosis and treatment can lead to poor outcomes for patients. Researchers reviewed root cause analysis (RCA) reports to identify factors contributing to delays in diagnosis and treatment among surgical patients at the Veterans Health Administration. Of the 163 RCAs identified, 73% reflected delays in treatment, 15% reflected delays in diagnosis, and 12% reflected delays in surgery. Policies and processes (e.g., lack of standardized processes, procedures not followed correctly) was the largest contributing factor, followed by communication challenges, and equipment or supply issues.
Baartmans MC, Hooftman J, Zwaan L, et al. J Patient Saf. 2022;Epub Apr 21.
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.
Morsø L, Birkeland S, Walløe S, et al. Jt Comm J Qual Patient Saf. 2022;48:271-279.
Patient complaints can provide insights into safety threats and system weaknesses. This study used the healthcare complaints analysis tool (HCAT) to identify and categorize safety problems in emergency care. Most problems arose during examination/diagnosis and frequently resulted in diagnostic errors or errors of omission.
Lam D, Dominguez F, Leonard J, et al. BMJ Qual Saf. 2022;Epub Mar 22.
Trigger tools and incident reporting systems are two commonly used methods for detecting adverse events.  This retrospective study compared the performance of an electronic trigger tool plus manual screening versus existing incident reporting systems for identifying probable diagnostic errors among children with unplanned admissions following a prior emergency department (ED) visit. Of the diagnostic errors identified by the trigger tool and substantiated by manual review, less than 10% were identified through existing incident reporting systems.
Lamoureux C, Hanna TN, Sprecher D, et al. Emerg Radiol. 2021;28:1135-1141.
Teleradiology - general radiologists who support several hospitals and read films remotely – can increase off-hours coverage but this approach can result in increased errors. This retrospective review examined errors and discrepancies between teleradiology findings and image interpretation from local facility radiologists. Most errors involved CT scans; the most common errors included missed fractures or dislocations and bleeding.
Shen L, Levie A, Singh H, et al. Jt Comm J Qual Patient Saf. 2022;48:71-80.
The COVID-19 pandemic has exacerbated existing challenges associated with diagnostic error. This study used natural language processing to identify and categorize diagnostic errors occurring during the pandemic. The study compared a review of all patient safety reports explicitly mentioning COVID-19, and using natural language processing, identified additional safety reports involving COVID-19 diagnostic errors and delays. This innovative approach may be useful for organizations wanting to identify emerging risks, including safety concerns related to COVID-19.
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.
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.
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.
Nikouline A, Quirion A, Jung JJ, et al. CJEM. 2021;23:537–546.
Trauma resuscitation is a complex, specialized care process with a high risk for errors. This systematic review identified 39 unique errors occurring in trauma resuscitation involving emergency medical services (EMS) handover; airway management; inadequate assessment and/or management of injuries; inadequate monitoring, transfusion/blood-related errors; team communication errors; procedure-related errors; or errors in disposition.

Cifra CL, Westlund E, Ten Eyck P, et al. Diagnosis (Berl). 2021;8(2):193-198. doi: 10.1515/dx-2020-0023.

Missed sepsis diagnosis can lead to increased morbidity, mortality and length of stay. Using administrative data, this retrospective study estimated the risk of potentially missed pediatric sepsis in several emergency departments. Approximately 8% of pediatric patients admitted to the hospital with sepsis experienced a treat-and-release emergency department visit within the prior 7 days. Administrative data can be helpful for hospitals in identifying cases that require detailed record review as well as evaluating the impact of sepsis alerts and bundles.
Perry MF, Melvin JE, Kasick RT, et al. J Pediatr. 2021;232:257-263.
Diagnostic errors remain an ongoing patient safety challenge and can result in patient harm. This article describes one large pediatric hospital's experience using a systematic methodology to identify and measure diagnostic errors. The quality improvement (QI) project used five domains (autopsy reports, root cause analyses (RCAs), voluntary reporting system, morbidity & mortality conference, and abdominal pain trigger tool) and adjudication by a QI team to identify cases of diagnostic error; Morbidity & mortality conferences, RCAs and abdominal trigger tool identified the majority (91%) of diagnostic errors.   
Mahajan P, Pai C-W, Cosby KS, et al. Diagnosis (Berl). 2021;8:340-346.
Diagnostic error is an ongoing patient safety challenge that can result in patient harm. This literature review identified a set of emergency department (ED)-focused electronic health record (EHR) triggers (e.g., death following ED visit, change in treating service after admission, unscheduled return to the ED resulting in admission) and non-EHR based signals (e.g., patient complaints, referral to risk management) with the potential to screen ED visits for diagnostic safety events.
Khalatbari H, Menashe SJ, Otto RK, et al. Pediatr Radiol. 2020;50:1409-1420.
This study reviewed safety events involving diagnostic or interventional radiology at one children’s hospital and used data from the root cause analyses to characterize the contributing system failures and key activities and processes. Approximately one-quarter of the safety events were secondary to diagnostic errors.  The most common key processes involved in these events were diagnostic and procedural services, and the most common key activities were interpreting/analyzing and coordinating activities.

Furrow BR. NE Univ Law Rev. 2020;12(1):1-55.

Artificial intelligence (AI) has the potential to improve the use of big data to enhance diagnosis, clinical performance improvement and financial risk avoidance. This article examines the role AI can play in tracking adverse incidents in hospitals to target and reduce systemic factors that contribute to patient harm.
Newman-Toker DE, Wang Z, Zhu Y, et al. Diagnosis (Berl). 2021;8:67-84.
Prior research based on claims data found that fifteen conditions related to vascular events, infections, and cancers (the ‘Big Three’) account for approximately 50% of all serious misdiagnosis-related harm. Based on a review of 28 studies representing over 91,000 patients, these authors estimated that the median diagnostic error rates for these conditions was 13.6%, ranging from 2.2% (myocardial infarction) to 62.1% (spinal abscess). The median serious misdiagnosis-related harm rate was estimated to be 5.5%, ranging from 1.2% (myocardial infarction) to 35.6% (spinal abscess).
Grubenhoff JA, Ziniel SI, Cifra CL, et al. Pediatr Qual Saf. 2020;5:e259.
Over a 2-month period, researchers surveyed pediatric clinicians to asses their comfort discussing medical errors (involving both systems and individual clinician responsibility) during morbidity & mortality conferences and privately with their peers. Respondents were least comfortable publicly discussing errors and were significantly less comfortable discussing diagnostic errors compared with other medical errors. The greatest barriers to discussing errors involved public perception of clinical performance.   
Gill S, Mills PD, Watts BV, et al. J Patient Saf. 2021;17:e898-e903.
This retrospective cohort study used root cause analysis (RCA) to examine safety reports from emergency departments at Veterans Health Administration hospitals over a two-year period. Of the 144 cases identified, the majority involved delays in care (26%), elopements (15%), suicide attempts and deaths (10%), inappropriate discharges (10%) and errors following procedures (10%). RCA revealed that primary contributory factors leading to adverse events were knowledge/educational deficits (11%) and policies/procedures that were either inadequate (11%) or lacking standardization (10%).