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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.
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.
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%).
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.
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.
Liu D, Gan R, Zhang W, et al. J Clin Pathol. 2018;71:67-71.
Autopsies are an underutilized tool for identifying diagnostic errors. Researchers evaluated 117 autopsies for patients in Shanghai whose cause of death was disputed or required third-party investigation. Diagnostic errors that would have altered treatment or survival were found in nearly 61%. This number is higher than estimates from a previous systematic review, likely because all patients in this sample had a disputed cause of death.
Obermeyer Z, Cohn B, Wilson M, et al. BMJ. 2017;356:j239.
The emergency department is considered a high-risk setting for diagnostic errors. This analysis of Medicare claims data found that a significant number of adults age 65–89 died within a week of visiting and being discharged from an emergency department, even when no life-limiting illness was noted. Hospitals that admit a lower proportion of emergency department patients to the inpatient setting had a higher mortality rate among discharged patients, even after adjusting for patient characteristics. Consistent with prior studies relating patient outcomes to volume, higher-volume emergency departments had lower 7-day mortality among discharged patients. These results suggest that emergency department discharges may represent missed diagnoses. A WebM&M commentary discussed an incident involving a patient who died after being discharged from the emergency department.
Davalos MC, Samuels K, Meyer AND, et al. Pediatr Crit Care Med. 2017;18:265-271.
Despite increased focus on improving diagnosis as a major patient safety issue, measuring and defining diagnostic error remains challenging. A prior study showed that application of the Safer Dx Instrument—a structured tool to help identify diagnostic errors in the primary care setting—enabled improved detection of diagnostic errors compared to chart review alone. In this study, researchers tested the ability of the instrument to identify diagnostic errors in high-risk patients admitted to the pediatric intensive care unit. Out of 214 high-risk patient charts, 26 were found to contain a diagnostic error. Two clinicians independently reviewed the records using the tool and reviewer agreement was 93.6%, suggesting that the Safer Dx Instrument may be useful in additional clinical settings. An Annual Perspective discussed the challenges associated with diagnostic error.
Jones A, Johnstone M-J. Aust Crit Care. 2017;30:219-223.
This qualitative study combined the narratives of various critical care nurses into four representative scenarios demonstrating failure to recognize clinically deteriorating patients. The authors describe inattentional blindness, a concept in which individuals in high-complexity environments can miss an important event because of competing attentional tasks, as a key factor in these failure-to-rescue events.
Medford-Davis L, Park E, Shlamovitz G, et al. Emerg Med J. 2016;33:253-9.
This retrospective study included chart reviews of adult patients who presented to an emergency department with abdominal pain and were identified via an electronic trigger as high-risk for diagnostic error. Researchers determined that diagnostic errors occurred in 35 of 100 reviewed cases, with the majority involving a breakdown in history-taking, test ordering, or abnormal test result follow-up.
Okafor N, Payne VL, Chathampally Y, et al. Emerg Med J. 2016;33:245-252.
Diagnostic errors are an understudied patient safety problem. The emergency department is a particularly challenging environment for diagnosis, due to its fast pace, frequent interruptions, and multiple simultaneous diagnostic trajectories. This study examined voluntary incident reports for diagnostic errors and found that common conditions such as sepsis and acute coronary syndromes were among the most frequently reported as missed or delayed. As with prior studies, the majority of errors involved multiple factors. Cognitive errors and system factors (e.g., inefficient processes and high workload) were prevalent. These results demonstrate the need to address diagnostic safety with both cognitive training interventions and systems approaches.
Moy E, Barrett M, Coffey R, et al. Diagnosis (Berl). 2015;2:29-40.
Although missed and delayed diagnoses are known to contribute to morbidity and mortality, measuring the extent of their impact on patient safety remains a challenge. In this study, researchers sought to identify missed diagnosis of acute myocardial infarction (AMI) using administrative data, an approach similar to prior studies of diagnostic accuracy. They suggest that patients treated in the emergency department for chest pain or a cardiac condition and released, who were then hospitalized for AMI within 7 days of that visit experienced a missed AMI diagnosis. The authors estimate that nearly 1% of AMI admissions represent a prior missed diagnosis. Younger patients and black patients had higher odds of missed diagnosis, raising concerns for disparities in the diagnostic process. Conversely, teaching hospital status and availability of cardiac catheterization were associated with lower odds of missed diagnosis, suggesting that settings where AMI is more commonly treated have higher diagnostic accuracy, mirroring earlier research on cognition and diagnosis. This study represents a promising approach for identifying missed diagnosis for other common conditions using available data.
Custer JW, Winters BD, Goode V, et al. Pediatr Crit Care Med. 2015;16:29-36.
Previous autopsy studies have found an error rate of nearly 9%, implying that thousands of patients die every year due to diagnostic errors. This systemic review of diagnostic errors in pediatric and neonatal intensive care unit (ICU) settings synthesized results of 13 studies of autopsies that confirmed diagnostic errors. The most common type of missed diagnosis found at autopsy was infection. Other prevalent missed diagnoses included vascular events and congenital conditions. The authors estimate that 6.4% of pediatric ICU deaths and 3.7% of neonatal ICU deaths are attributable to major missed diagnosis. This work argues for more prospective investigation of missed and delayed diagnoses as well as more routine autopsies in pediatric and neonatal ICU settings. A past AHRQ WebM&M commentary discussed the value of autopsies in understanding misdiagnoses.
Vioque SM, Kim PK, McMaster J, et al. Am J Surg. 2014;208:187-194.
Approximately 1 in 13 deaths of patients with major trauma were considered preventable or potentially preventable in this retrospective review from an urban trauma center. Diagnostic errors during the initial trauma assessment were a frequent contributor to preventable harm.
Newman-Toker DE, Moy E, Valente E, et al. Diagnosis (Berl). 2014;1:155-166.
This observational study identified patients who visited the emergency department within 30 days prior to a stroke diagnosis. Nearly 13% of patients had a potential missed diagnosis, and more than 1% had a probable missed diagnosis of stroke. This study illustrates a novel approach to characterizing the incidence of missed diagnosis, an important and understudied patient safety problem.
Glance LG, Osler TM, Neuman MD. N Engl J Med. 2014;370:1379-1381.
Discussing communication weaknesses in surgery, this commentary examines how team-based decision making can contribute to safer and more patient-centered care in this setting, particularly for complex cases. The authors advocate for an enhanced safety culture to support better communication.
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.
Winters B, Custer J, Galvagno SM, et al. BMJ Qual Saf. 2012;21:894-902.
In the quest to improve patient safety, diagnostic errors have been underemphasized and as a result have been termed the "next frontier" for the safety field. This systematic review of autopsy studies sought to estimate the incidence of diagnostic errors contributing to death (class I errors) in intensive care unit (ICU) patients, compared with a prior systematic review that identified a 4.1% class I error rate across all patients undergoing autopsy. This review, which included 31 separate studies, found an overall class I error rate of 8% in ICU patients, with vascular events and infections accounting for most missed diagnoses. Despite the continuing utility of autopsies in improving diagnostic performance, autopsy rates in the United States have been steadily declining, leading to calls for efforts to increase autopsy rates.