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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.
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.
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.
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%).
Abe T, Tokuda Y, Shiraishi A, et al. Crit Care. 2019;23:202.
This retrospective study sought to determine whether timely diagnosis of the site of infection affected in-hospital mortality for sepsis. Investigators found that patients whose infection site was misdiagnosed on admission had more than twofold greater odds of dying in the hospital compared to those with the correct infection site diagnosed on admission. These results reinforce the importance of correct and timely diagnosis for sepsis outcomes.
Wright B, Faulkner N, Bragge P, et al. Diagnosis (Berl). 2019;6:325-334.
The hectic pace of emergency care detracts from reliability. This review examined the literature on evidence, practice, and patient perspectives regarding diagnostic error in the emergency room. A WebM&M commentary discussed an incident involving a diagnostic delay in the emergency department.
Fitzsimons BT, Fitzsimons LL, Sun LR. Pediatrics. 2019;143:e20183458.
Rare diseases pose diagnostic challenges for physicians. This commentary offers insights from parents of a young child who died due to a delayed stroke diagnosis as well as from the patient's neurologist to raise awareness of childhood stroke and discuss the importance of partnership to heal from loss and advocate for improvement.
Medford-Davis LN, Singh H, Mahajan P. Pediatr Clin North Am. 2018;65:1097-1105.
The busy and complex emergency department environment harbors pressures can that hinder diagnostic safety. This review discusses the characteristics of emergency medicine that contribute to overreliance on heuristics and susceptibility to bias in decision making. The authors highlight the need to better monitor diagnostic error in the emergency department to inform the design of improvement activities. A previous WebM&M commentary discussed diagnostic delay in the emergency department.
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.
Sundberg M, Perron CO, Kimia A, et al. Diagnosis (Berl). 2018;5:63-69.
In the Improving Diagnosis report, the National Academy of Medicine called for broad-scale efforts to reduce diagnostic errors. This retrospective cohort study employed natural language processing to identify dangerous diagnoses that pediatric emergency medicine physicians missed. A past WebM&M commentary laid out challenges in classifying diagnostic errors.
Chu D, Xiao J, Shah P, et al. Diagnosis (Berl). 2018;5:143-150.
This retrospective review of cases presented at one hospital's emergency medicine morbidity and mortality (M&M) conferences found that more than half involved a diagnostic error, most of which were a cognitive error. When present, cognitive errors were more frequently ascribed to faulty data synthesis rather than a knowledge deficit.
Lemoine N, Dajer A, Konwinski J, et al. J Healthc Risk Manag. 2018;38:48-53.
Analysis of closed malpractice claims has been used to characterize safety hazards in a variety of clinical settings. This study used retrospective review of malpractice claims to examine the underlying causes of diagnostic error in the emergency department as well as identify potential systems solutions. The senior author of this study, Dr. Hardeep Singh, discussed the evolving diagnostic error field in a PSNet perspective.
Stoklosa H, Scannell M, Ma Z, et al. Emerg Med J. 2018;35:406-411.
Emergency department crowding is linked to medication errors and other preventable harm. Crowding requires providers to evaluate patients quickly under suboptimal conditions, such as in hallways or waiting rooms with inadequate nursing support, which may lead to diagnostic errors. This cross-sectional survey of emergency medicine physicians assessed how evaluating patients in the hallway or with a companion present changed their usual diagnostic practices. Researchers found that 90% of physicians altered their history-taking or physical examination, and 40% reported a diagnostic error or delay as a result. The most common missed diagnoses were suicidal ideation, abuse or neglect, and genitourinary system disease. A PSNet Perspective and a WebM&M commentary discussed strategies to reduce diagnostic errors in emergency departments.
Waxman DA, Kanzaria HK, Schriger DL. JAMA Intern Med. 2018;178:477-484.
Diagnostic error remains an ongoing challenge within patient safety. Using claims data, this retrospective study found that among Medicare patients presenting to the emergency department with symptoms consistent with ruptured abdominal aortic aneurysm, acute myocardial infarction (AMI), stroke, aortic dissection, and subarachnoid hemorrhage, between 2.3% (AMI) and 4.5% (aortic dissection) of patients were discharged without a diagnosis.
Bhat PN, Costello JM, Aiyagari R, et al. Cardiol Young. 2018;28:675-682.
Researchers surveyed pediatric cardiac intensive care unit providers across three tertiary cardiac centers in the United States. More than 80% of respondents perceived diagnostic errors to be common and 65% reported errors causing permanent harm to patients. Improving feedback and teamwork were frequently suggested as strategies for reducing diagnostic error.