Plint AC, Newton AS, Stang A, et al. BMJ Qual Saf. 2022;Epub Jul 19.
While adverse events (AE) in pediatric emergency departments are rare, the majority are considered preventable. This study reports on the proportion of pediatric patients experiencing an AE within 21 days of an emergency department visit, whether the AE may have been preventable, and the type of AE (e.g., management, diagnostic). Results show 3% of children experienced at least one AE, most of which were preventable.
Gupta K, Szymonifka J, Rivadeneira NA, et al. Jt Comm J Qual Patient Saf. 2022;Epub May 28.
Analysis of closed malpractice claims can be used to identify potential safety hazards in a variety of clinical settings. This analysis of closed emergency department malpractice claims indicates that diagnostic errors dominate, and clinical judgment and documentation categories continue to be associated with a higher likelihood of payout. Subcategories and contributing factors are also discussed.
Missed diagnosis of stroke in emergency medicine settings is an important patient safety problem. In this study, researchers interviewed emergency medicine physicians about their perspectives on diagnostic neurology and use of clinical decision support (CDS) tools. Themes emerged related to challenges in diagnosis, neurological complaints, and challenges in diagnostic decision-making emergency medicine, more generally. Participating physicians were enthusiastic about the possibility of involving CDS tools to improve diagnosis for non-specific neurological complaints.
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%.
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.
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.
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.
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.
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.
Bergl PA, Nanchal RS, Singh H. Ann Am Thorac Soc. 2018;15:903-907.
Elements of critical care can influence the reliability of diagnosis, teamwork, and care delivery. This commentary recommends areas for research to reduce diagnostic error in the intensive care unit. The authors highlight the need for intensivist involvement to define distinct roles and actions in their specialty for diagnostic improvement.
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.
Zachariasse JM, Kuiper JW, de Hoog M, et al. J Pediatr. 2016;177:232-237.e1.
Emergency department triage systems are designed to prioritize patients based on the level of illness. Inappropriate triage can lead to delays in care and adverse events. In Europe, the Manchester Triage System is a widely used algorithm that classifies patients based on five levels of urgency with a corresponding maximum waiting time. This study sought to assess the effectiveness of the Manchester Triage System in children requiring admission to the intensive care unit (ICU). Analyzing more than 50,000 consecutive emergency department visits of children younger than 16, the authors determined that almost one third of children admitted to the ICU were undertriaged. Risk factors identified for undertriage included age younger than 3 months, type of medical presenting problem, presence of underlying chronic conditions, referral by a specialist or emergency medical services, and arrival during the evening or at night. These findings suggest that the Manchester Triage System inappropriately triages a significant proportion of children requiring ICU admission and that modifications should be made to improve safety in pediatric emergency care. A previous WebM&M commentary discussed the challenges of triage in the emergency department.
Bashkin O, Caspi S, Swissa A, et al. J Patient Saf. 2020;16:47-51.
This pre-post study found that a human factors approach improved blood collection procedures in the emergency department, which is important for preventing adverse events such as transfusion errors. This demonstrates the benefits of applying human factors engineering in patient safety efforts across health care settings.
Jones SL, Ashton CM, Kiehne L, et al. Jt Comm J Qual Patient Saf. 2015;41:483-91.
A protocolized early warning system to improve sepsis recognition and management was associated with a decrease in sepsis-related inpatient mortality. The protocol emphasized early recognition by nurses and escalation of care by a nurse practitioner when indicated. An AHRQ WebM&M commentary describes common errors in the early management of sepsis.
Murray DJ, Freeman BD, Boulet JR, et al. Simul Healthc. 2015;10:139-145.
Simulation training has been used to improve patient safety across multiple care settings. This study sought to enhance diagnostic accuracy for trauma care among resident-level trainees. Researchers developed several standardized cases to assess care for a patient presenting with severe injury. Some scenarios were algorithmic and others required more analysis. Residents with more years of training performed better on the simpler scenarios but worse on the analytic scenarios which required that they reassess their diagnosis. This finding suggests that those with more experience assimilated the algorithms more readily, but they also continue to need cognitive training for diagnostic accuracy. A past AHRQ WebM&M interview with Dr. Pat Croskerry discusses the need to enhance cognitive skills for diagnosis in medical training.
This study used written medical cases to examine whether simulated time pressure or interruptions affect diagnostic accuracy among resident and attending emergency medicine physicians. While the experienced physicians answered the questions more quickly and accurately compared to resident physicians, diagnostic accuracy was not compromised by time pressure or interruptions for either group in this study.
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.
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