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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.
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.
Shafer GJ, Singh H, Thomas EJ, et al. J Perinatol. 2022;Epub Mar 4.
Patients in the neonatal intensive care unit (NICU) are at risk for serious patient safety threats. In this retrospective review of 600 consecutive inborn NICU admissions, researchers found that the frequency of diagnostic errors among inborn NICU patients during the first seven days of admission was 6.2%.
Bastakoti M, Muhailan M, Nassar A, et al. Diagnosis. 2022;9:107-114.
Misdiagnosis in the emergency department (ED) can result in increased morbidity and mortality. This retrospective chart review of patients admitted from the ED to hospital explored the concordance of ED admission and hospital discharge diagnoses. Results show 21.77% of patients had discordant diagnoses; discordant diagnosis was associated with increased length of stay, mortality, and up-triage to ICU.
Cooper A, Carson-Stevens A, Cooke M, et al. BMC Emerg Med. 2021;21:139.
Overcrowding in the emergency department (ED) can result in increased frequency of medication errors, in-hospital cardiac arrest, and other patient safety concerns. This study examined diagnostic errors after introducing a new healthcare service model in which emergency departments are co-located with general practitioner (GP) services. Potential priority areas for improvement include appropriate triage, diagnostic test interpretation, and communication between GP and ED services.
Nassery N, Horberg MA, Rubenstein KB, et al. Diagnosis (Berl). 2021;8:469-478.
Building on prior research on missed myocardial infarction, this study used the SPADE approach to identify delays in sepsis diagnosis. Using claims data, researchers used a ‘look back’ analysis to identify treat-and-release emergency department (ED) visits in the month prior to sepsis hospitalizations and identify common diagnoses linked to downstream sepsis hospitalizations.
Kukielka E. Patient Saf. 2021;3:18-27.
Trauma patients, who often suffer multiple, severe injuries and who may arrive to the Emergency Department (ED) unconscious, are vulnerable to adverse events. Using data reported to the Pennsylvania Patient Safety Reporting System (PA-PSRS), researchers in this study evaluated the safety challenges of caring for patients presenting to the ED after a motor vehicle collision. Common challenges included issues with monitoring, treatment, evaluation, and/or documentation, patient falls, medication errors, and problems with transfers.
Michelson KA, Reeves SD, Grubenhoff JA, et al. JAMA Netw Open. 2021;4:e2122248.
Diagnostic errors, including delayed diagnoses, continue to be a patient safety concern. This case-control study of children treated at five pediatric emergency departments explored the preventability of delayed diagnosis of pediatric appendicitis and associated outcomes. Researchers estimated that 23% of delayed diagnosis cases were likely to be preventable and that delayed diagnosis led to longer hospital length of stay, higher perforation rates, and additional surgical procedures.
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.
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.
Driessen RGH, Latten BGH, Bergmans DCJJ, et al. Virchows Arch. 2020;478:1173-1178.
Autopsies are an important tool for detecting misdiagnoses. Autopsies were performed on 32 septic individuals who died within 48 hours of admission to the intensive care unit. Of those, four patients were found to have class I missed major diagnosis. These results underscore the need to perform autopsies to improve diagnosis.
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.
Horberg MA, Nassery N, Rubenstein KB, et al. Diagnosis (Berl). 2021;8:479-488.
Missed or delayed diagnosis of sepsis can lead to serious patient harm. This study used a Symptom-Disease Pair Analysis of Diagnostic Error (SPADE) “look-forward” analysis to measure potential misdiagnosis of sepsis in patients discharged from the emergency department (ED) with treat-and-release fluid and electrolyte disorders (FED) or altered mental status (AMS). FED and AMS were associated with a spike in sepsis hospitalizations in the 7-day period following the ED visit. The authors suggest SPADE could be used to compare sepsis diagnostic performance across institutions and regions; develop interventions for targeted subgroups; and update early warning systems for sepsis diagnosis.
Cifra CL, Custer JW, Singh H, et al. Pediatr Crit Care Med. 2021;22:701-712.
Diagnostic errors continue to be a patient safety concern, including in pediatric critical care. This systematic review explored the prevalence, impact, and contributing factors to diagnostic errors in the pediatric intensive care unit (PICU). The most common diagnostic errors occurred in cardiovascular, infectious, congenital, and neurologic conditions; cognitive and systems factors were associated with diagnostic errors. Future research should focus on disease- and systems-level determinants. 
Hensgens RL, El Moumni M, IJpma FFA, et al. Eur J Trauma Emerg Surg. 2020;46:1367-1374.
Missed injuries and delayed diagnoses are an ongoing problem in trauma care. This cohort study conducted at a large trauma center found that inter-hospital transfer of severely injured patients increases the risk of delayed detection of injuries. For half of these patients, the new diagnoses led to a change in treatment course. These findings highlight the importance of clinician vigilance when assessing trauma patients.
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.
Sharp AL, Baecker A, Nassery N, et al. Diagnosis (Berl). 2021;8:177-186.
The symptom-disease pair analysis of diagnostic error approach, or SPADE approach, measures diagnostic errors resulting in adverse events using two analytic pathways – the ‘look back’ analysis identifies symptoms associated with adverse events and identifies the symptom-specific harm rate per hospitalization and the ‘look forward’ analysis measures the disease-specific harm rate per symptomatic discharge. Using data from 2009 to 2017, this retrospective analysis looked at Emergency Department (ED) visits within 30 days of a hospitalization for acute myocardial infarction (AMI) to identify symptoms linked to probable missed diagnoses. Within 30 days of a subsequent hospitalization for AMI, common ED discharge diagnoses included chest pain and dyspnea, representing 574 probable missed AMIs. The authors estimate that these results correspond to approximately 10,000 potentially-preventable harms annually in the United States.  
Mahajan P, Basu T, Pai C-W, et al. JAMA Netw Open. 2020;3:e200612.
Using data from a large commercial insurance claims database, this cohort study sought to identify factors associated with potentially missed appendicitis by comparing patients with a potentially missed diagnosis versus patients diagnosed with appendicitis on the same day in the emergency department. The researchers estimated the frequency of missed appendicitis was 6% among adults and 4.4% among children. Patients presenting with abdominal pain and constipation were more likely to have a missed diagnosis of appendicitis than patients presenting with isolated abdominal pain or abdominal pain with nausea and/or vomiting. Stratified analyses based on undifferentiated symptoms found that women and patients with comorbidities were more likely to have missed appendicitis.