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NIHCM Foundation. Washington DC: National Institute for Health Care Management. August 2, 2022.

Preventable maternal morbidity is an ongoing challenge in the United States. This infographic shares general data and statistics that demonstrate the presence of racial disparities in maternal care that are linked to structural racism. The resource highlights several avenues for improvement such as diversification of the perinatal staffing and increased access to telehealth.
Atallah F, Hamm RF, Davidson CM, et al. Am J Obstet Gynecol. 2022;227:B2-B10.
The reduction of cognitive bias is generating increased interest as a diagnostic error reduction strategy. This statement introduces the concept of cognitive bias and discusses methods to manage the presence of bias in obstetrics such as debiasing training and teamwork.
Li W, Stimec J, Camp M, et al. J Emerg Med. 2022;62:524-533.
While pediatric musculoskeletal radiograph misinterpretations are rare, it is important to know what features of the image area are associated with false-positive or false-negative diagnoses. In this study, pediatric emergency medicine physicians were asked to interpret radiographs with and without known fractures. False-positive diagnosis (i.e., a fracture was identified when there was none) were reviewed by an expert panel to identify the location and anatomy most prone to misdiagnosis.
Dregmans E, Kaal AG, Meziyerh S, et al. JAMA Netw Open. 2022;5:e2218172.
Inappropriate antibiotic prescribing can result in patient harm and costly antibiotic-resistant infections. Health record review of 1,477 patients admitted from the emergency department for suspected bacteremia infection revealed that 11.6% were misdiagnosed at infection site, and 3.1% did not have any infection. Misdiagnosis was not associated with worse short-term clinical outcomes but was associated with potentially inappropriate broad-spectrum antibiotic use.

A 58-year-old man with a past medical history of seizures presented to the emergency department (ED) with acute onset of left gaze deviation, expressive aphasia, and right-sided hemiparesis. The patient was evaluated by the general neurology team in the ED, who suspected an acute ischemic stroke and requested an evaluation by the stroke neurology team but did not activate a stroke alert. The stroke team concluded that the patient had suffered a focal seizure prior to arrival and had postictal deficits.

Liberman AL, Cheng NT, Friedman BW, et al. Diagnosis (Berl). 2022;9:225-235.
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.
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.
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%.

A 69-year-old man with End-Stage Kidney Disease (ESKD) secondary to diabetes mellitus and hypertension, who had been on dialysis since 2014, underwent deceased donor kidney transplant. The case demonstrates the complex nature of management of allograft dysfunction due to vascular complications in a patient with deceased donor kidney transplant in the early post-transplant period.

The Revised Safer Dx Instrument provides a standardized list of questions to help users retrospectively identify and assess the likelihood of a missed diagnosis in a healthcare episode. Results of the assessment are intended for use in system-level safety improvement efforts, clinician feedback, and patient safety research.

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.

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.

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.

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.

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.

A pregnant patient was admitted for scheduled Cesarean delivery, before being tested according to a universal inpatient screening protocol for SARS-CoV-2. During surgery, the patient developed a fever and required oxygen supplementation. Due to suspicion for COVID-19, a specimen obtained via nasopharyngeal swab was sent to a commercial laboratory for reverse transcriptase polymerase chain reaction (RT-PCR) testing.

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.
Bhat A, Mahajan V, Wolfe N. J Clin Neurosci. 2021;85:27-35.
Misdiagnosis, variation in treatment of stroke and gaps in secondary prevention in young patients can result in adverse outcomes. This article discusses the possible causes of implicit bias in stroke care in this population, the effects of bias on patient outcomes, and interventions to circumvent implicit bias.  

A 60-year-old male presented to the emergency department (ED) with his partner after an episode of dizziness and syncope when exercising. An electrocardiogram demonstrated non-ST-elevation myocardial infarction abnormalities. A brain CT scan was ordered but the images were not assessed prior to initiation of anticoagulation treatment. While awaiting further testing, the patient’s heart rate slowed and a full-body CT scan demonstrated an intracranial hemorrhage. An emergent craniotomy was performed and the patient later died.