Skip to main content

All Content

Search Tips
Save
Selection
Format
Download
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Narrow Results By
Additional Filters
1 - 20 of 90
Salwei ME, Hoonakker PLT, Carayon P, et al. Hum Factors. 2022;Epub Apr 4.
Clinical decision support (CDS) systems are designed to improve diagnosis. Researchers surveyed emergency department physicians about their evaluation of human factors-based CDS systems to improve diagnosis of pulmonary embolism. Although perceived usability was high, use of the CDS tool in the real clinical environment was low; the authors identified several barriers to use, including lack of workflow integration.
Patel SJ, Ipsaro A, Brady PW. Hosp Pediatr. 2022;Epub Feb 28.
Diagnostic uncertainty can arise in complex clinical scenarios. This qualitative study explored how physicians in pediatric emergency and inpatient settings mitigate diagnostic uncertainty. Participants discussed common mitigation strategies, such as employing a “diagnostic pause.” The authors also noted outstanding gaps regarding communicating diagnostic uncertainty to families.
Yale S, Cohen S, Bordini BJ. Crit Care Clin. 2022;38:185-194.
A broad differential diagnosis can limit missed diagnostic opportunities. This article outlines how diagnostic timeouts, which are intended reduce bias during the identification of differential diagnoses, can improve diagnosis and reduce errors.
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.
Gibson BA, McKinnon E, Bentley RC, et al. Arch Pathol Lab Med. 2021;Epub Oct 21.
A shared understanding of terminology is critical to providing appropriate treatment and care. This study assessed pathologist and clinician agreement of commonly-used phrases used to describe diagnostic uncertainty in surgical pathology reports. Phrases with the strongest agreement in meaning were “diagnostic of” and “consistent with”. “Suspicious for” and “compatible with” had the weakest agreement. Standardized diagnostic terms may improve communication.
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.
Halsey-Nichols M, McCoin N. Emerg Med Clin North Am. 2021;39:703-717.
Diagnostic errors among patients presenting to the emergency department (ED) with abdominal pain are common. This article summarizes the factors associated with missed diagnoses of abdominal pain in the ED, the types of abdominal pain that are commonly misdiagnosed, and recommended steps for discharging a patient with abdominal pain without a final diagnosis.
Ly DP. Ann Emerg Med. 2021;78:650-657.
A common type of diagnostic error is availability bias, or diagnosing a patient based on experiences with past similar cases. This study examined whether an emergency physician’s recent experience of a patient presenting with shortness of breath and diagnosed with pulmonary embolism increased subsequent pulmonary embolism diagnoses. While pulmonary embolism diagnosis did increase over the following ten days, that effect did not persist over the 50 days following the first 10 days.
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.
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.
Kasick RT, Melvin JE, Perera ST, et al. Diagnosis (Berl). 2021;8:209-217.
Diagnostic errors can result in increased length of stay and unplanned hospital readmissions. To reduce readmissions, this hospital implemented a diagnostic time-out to increase the frequency of documented differential diagnosis in pediatric patients admitted with abdominal pain. Results showed marginal improvement in quality of differential 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.
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.  
Brown SD. Pediatr Radiol. 2021;51:1070-1075.
Misdiagnosis of child abuse has far-reaching implications. This commentary discusses the ethical tensions faced by pediatric radiologists of both over- and under-diagnosing child abuse. The author suggests ways that physicians and professional societies can partner with legal advocates to create a more balanced pool of experts to alleviate perceptions of bias and acknowledge harms of misdiagnosed child abuse.

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.
Barwise A, Leppin A, Dong Y, et al. J Patient Saf. 2021;17:239-248.
Diagnostic errors and delays continue to be a widespread patient safety concern in hospitalized patients. Researchers conducted focus groups with key clinician stakeholders to determine factors that contribute to diagnostic error and delay. Clinicians indicated that organizational, interactional, clinician, and patient factors all interact to cause errors and delays. These diverse factors must be considered when implementing interventions to reduce diagnostic errors and delays.