The PSNet Collection

Learning from diagnostic errors to improve patient safety when GPs work in or alongside emergency departments: incorporating realist methodology into patient safety incident report analysis.

Cooper A, Carson-Stevens A, Cooke M, et al. BMC Emerg Med. 2021;21(1):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.

Communicating certainty in pathology reports: interpretation differences among staff pathologists, clinicians, and residents in a multicenter study.

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.

Antecedent treat-and-release diagnoses prior to sepsis hospitalization among adult emergency department patients: a look-back analysis employing insurance claims data using Symptom-Disease Pair Analysis of Diagnostic Error (SPADE) methodology.

Nassery N, Horberg MA, Rubenstein KB, et al. Diagnosis (Berl). 2021;8(4):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.

Diagnostic Excellence in the ICU: Thinking Critically and Masterfully.

Bergl PA, Nanchal RS, eds. Crit Care Clin. 2022;38(1):1-158.

Critical care diagnosis is complicated by factors such as stress, patient acuity and uncertainty. This special issue summarizes individual and process challenges to the safety of diagnosis in critical care. Articles included examine educational approaches, teamwork and rethinking care processes as improvement strategies.

Abdominal pain in the emergency department: missed diagnoses.

Halsey-Nichols M, McCoin N. Emerg Med Clin North Am. 2021;39(4):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.

The influence of the availability heuristic on physicians in the emergency department.

Ly DP. Ann Emerg Med. 2021;78(5):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.

The Contribution of Diagnostic Errors to Maternal Morbidity and Mortality During and Immediately After Childbirth: State of the Science.

Bajaj K, de Roche A, Goffman D. Rockville, MD: Agency for Healthcare Research and Quality; September 2021. AHRQ Publication No. 20(21)-0040-6-EF.

Maternal safety is threatened by systemic biases, care complexities, and diagnostic issues. This issue brief explores the role of diagnostic error in maternal morbidity and mortality, the preventability of common problems such as maternal hemorrhage, and the importance of multidisciplinary efforts to realize improvement. The brief focuses on events occurring during childbirth and up to a week postpartum.

Safety events impacting hospitalized patients following motor vehicle crashes: a qualitative study of reports from Pennsylvania hospitals.

Kukielka E. Patient Saf. 2021;3(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.

Dangers of Missing an Epidural Abscess: Multiple Visits and Delayed Diagnosis with a Severely Negative Outcome

September 29, 2021

A 44-year-old man presented to his primary care physician (PCP) with complaints of new onset headache, photophobia, and upper respiratory tract infections. He had a recent history of interferon treatment for Hepatitis C infection and a remote history of cervical spine surgery requiring permanent spinal hardware. On physical examination, his neck was tender, but he had no neurologic abnormalities. He was sent home from the clinic with advice to take over-the-counter analgesics.

Clinical features and preventability of delayed diagnosis of pediatric appendicitis.

Michelson KA, Reeves SD, Grubenhoff JA, et al. JAMA Netw Open. 2021;4(8):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.

Maternal Safety

Ensuring maternal safety is a patient safety priority. This library reflects a curated selection of PSNet content focused on improving maternal safety. Included resources explore strategies with the potential to improve maternal care delivery and outcomes, such as high reliability, care standardization, teamwork, unit-based safety initiatives, and trigger tools.

Coming up for Err – Missed Diagnosis in a Patient with Recurrent Pneumothorax

August 25, 2021

A 31-year-old woman presented to the ED with worsening shortness of breath and was unexpectedly found to have a moderate-sized left pneumothorax, which was treated via a thoracostomy tube. After additional work-up and computed tomography (CT) imaging, she was told that she had some blebs and mild emphysema, but was discharged without any specific follow-up instructions except to see her primary care physician.

Learning from patient safety incidents involving acutely sick adults in hospital assessment units in England and Wales: a mixed methods analysis for quality improvement.

Urquhart A, Yardley S, Thomas E, et al. J R Soc Med. 2021;Epub Aug 4.

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.

Validation of an electronic trigger to measure missed diagnosis of stroke in emergency departments.

Vaghani V, Wei L, Mushtaq U, et al. J Am Med Inform Assoc. 2021;28(10):2202-2211.

Based on the SaferDx 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.

Clinical diagnoses vs. autopsy findings in early deceased septic patients in the intensive care: a retrospective cohort study.

Driessen RGH, Latten BGH, Bergmans DCJJ, et al. Virchows Arch. 2020;478(6):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.

A diagnostic time-out to improve differential diagnosis in pediatric abdominal pain.

Kasick RT, Melvin JE, Perera ST, et al. Diagnosis (Berl). 2021;8(2):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.

Errors in adult trauma resuscitation: a systematic review.

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.

Paroxysmal Supraventricular Tachycardia Masquerading as Panic Attacks

June 30, 2021

Beginning in her teenage years, a woman began "feeling woozy" after high school gym class. The symptoms were abrupt in onset, lasted between 5 to 15 minutes and then subsided after sitting down. Similar episodes occurred occasionally over the following decade, usually related to stress. When she was in her 30s, she experienced a more severe episode of palpitations and went to the emergency department (ED). An electrocardiogram (ECG) was normal and she was discharged with a diagnosis of stress or possible panic attack.

AI for radiographic COVID-19 detection selects shortcuts over signal.

DeGrave AJ, Janizek JD, Lee S-I. Nature Machine Intel. 2021;Epub May 31.

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.

Ethical challenges in child abuse: what is the harm of a misdiagnosis?

Brown SD. Pediatr Radiol. 2021;51(6):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.

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