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.
Vaghani V, Wei L, Mushtaq U, et al. J Am Med Inform Assoc. 2021;28:2202-2211.
Based on the Safer Dx and SPADE frameworks, researchers applied a symptom-disease pair-based electronic trigger (e-trigger) to identify patients hospitalized for stroke who had been previously discharged from the emergency department with a diagnosis of headache or dizziness in the preceding 30 days. Analyses show that the e-trigger identified missed diagnoses of stroke with a modest positive predictive value.
DeGrave AJ, Janizek JD, Lee S-I. Nat Mach Intell. 2021;3:610–619.
Artificial intelligence (AI) systems can support diagnostic decision-making. This study evaluates diagnostic “shortcuts” learned by AI systems in detecting COVID-19 in chest radiographs. Results reveal a need for better training data, improved choice in the prediction task, and external validation of the AI system prior to dissemination and implementations in different hospitals.
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.
Thomas J, Dahm MR, Li J, et al. J Am Med Inform Assoc. 2020;27:1214–1224.
This qualitative study explored how clinicians ensure optimal management of diagnostic test results, a major patient safety concern. Thematic analyses identified strategies clinicians use to enhance test result management including paper-based manual processes, cognitive reminders, and adaptive use of electronic medical record functionality.
Aaronson E, Jansson P, Wittbold K, et al. Am J Emerg Med. 2020;38:1584-1587.
This study evaluated the efficacy of reviewing ED return visits that result in an ICU admission to determine if they were associated with deviations in care and to understand the common errors. They found that of patients who were return ED visits and admitted to the ICU, 44% (223 cases) returned for reasons associated with the index visit and, in those, 14% (31 cases) had a deviation in care at the index visit. Implementing a standard diagnostic process of care framework to those 31 cases with a deviation in care, 47.3% had a failure in the initial diagnostic pathway. The authors concluded reviewing 14 day returns with ICU admissions contribute to better understanding of diagnostic and systems errors.
Dubosh NM, Edlow JA, Goto T, et al. Ann Emerg Med. 2019;74:549-561.
Misdiagnosis of a neurologic emergency such as stroke can lead to serious morbidity or mortality. Using a large multi-state database, this study examined the likelihood of readmission or inpatient mortality among patients who were initially discharged with nonspecific diagnoses of headache or back pain and found that 0.5% of headache and 0.2% of back pain patients experienced an inpatient death or serious neurological event after ED discharge. Extrapolated to a national level, this translates to over 55,000 patients with adverse outcomes due to a missed diagnosis for headache or back pain.
Upadhyay DK, Sittig DF, Singh H. Diagnosis (Berl). 2014;1:283-287.
Misdiagnosis and errors linked to electronic health records (EHRs) are common concerns in patient safety. This commentary examines these elements in the context of the first Ebola case in the United States to reveal weaknesses in emergency department care, disaster management, and diagnostic processes. The case analysis highlights challenges associated with forming diagnoses and the usability of EHRs as decision support tools.
March CA, Steiger D, Scholl G, et al. BMJ Open. 2013;3.
Residents and fellows frequently failed to identify serious clinical abnormalities when asked to review the electronic medical record (EMR) of a simulated intensive care unit patient, indicating that the design of the EMR may affect situational awareness.
Murff HJ, FitzHenry F, Matheny ME, et al. JAMA. 2011;306:848-55.
Many adverse event identification methods cannot detect errors until well after the event has occurred, as they rely on screening administrative data or review of the entire chart after discharge. Electronic medical records (EMRs) offer several potential patient safety advantages, such as decision support for averting medication or diagnostic errors. This study, conducted in the Veterans Affairs system, reports on the successful development of algorithms for screening clinicians' notes within EMRs to detect postoperative complications. The algorithms accurately identified a range of postoperative adverse events, with a lower false negative rate than the Patient Safety Indicators. As the accompanying editorial notes, these results extend the patient safety possibilities of EMRs to potentially allow for real time identification of adverse events.
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