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Pinheiro LC, Reshetnyak E, Safford MM, et al. Med Care. 2021;Epub Aug 14.
Prior research has found that racial/ethnic minorities may be at higher risk for adverse patient safety outcomes. This study evaluated racial disparities in self-reported adverse events based on cross-sectional survey data collected as part of a national, prospective cohort evaluating stroke mortality. Findings show that Black participants were significantly more likely to report a preventable adverse event attributable to poor care coordination (e.g., drug-drug interaction, emergency department visitor, or hospitalization) compared to White participants.
Vaghani V, Wei L, Mushtaq U, et al. J Am Med Inform Assoc. 2021;Epub Jul 20.
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.
Chang T-P, Bery AK, Wang Z, et al. Diagnosis (Berl). 2021;Epub Jun 20.
A missed or delayed diagnosis of stroke increases the risk of permanent disability or death. This retrospective study compared rates of misdiagnosed stroke in patients presenting to general care or specialty care who were initially diagnosed with “benign dizziness”. Patients with dizziness who presented to general care were more likely to be misdiagnosed than those presenting to specialty care. Interventions to improve stroke diagnosis in emergency departments may also be successful in general care clinics.
Dancsecs KA, Nestor M, Bailey A, et al. Am J Emerg Med. 2021;47:90-94.
Alteplase and other thrombolytics are high-alert medications. This study compared error rates of alteplase administration in patients presenting with acute ischemic stroke at either a regional hospital or a Comprehensive Stroke Center (CSC) and found that community hospitals had over a 10 times greater number of errors leading to hemorrhage. The study recommend to put safeguards in place to decrease the risk of alteplase medication administration errors.
Mekonnen B, Wang G, Rajbhandari-Thapa J, et al. J Stroke Cerebrovasc Dis. 2020;29(10):105106.
The ”weekend effect” refers to worse patient outcomes occurring outside of usual business hours. The authors used national data to examine in-hospital mortality differences among patients experiencing stroke admitted on the weekend versus on a weekday. After adjusting for patient and hospital characteristics, in-hospital mortality among hemorrhagic stroke patients was significantly greater among weekend compared to weekday admissions. No weekend effect was found among ischemic stroke patients. Future research should explore the influence of additional factors, such as patient-level behavioral risk factors and the availability of care providers and stroke care centers, particularly in rural regions.  

Farnborough, UK; Healthcare Safety Investigation Branch. October 13, 2020

Errors of omission in routine care can result in patient harm. This report discusses factors contributing to a pulmonary embolism in a recovering stroke patient acerbated by a lack of intended but omitted venous thromboembolism or VTE preventative care. The system improvement recommendations drawn from the incident analysis include that the UK National Health Service develop a standardized approach to VTE risk assessment and broad-based training to enable a cross-section of clinicians to use VTE prevention devices as required.

Horowitz SH. Washington Post. October 4, 2020.

The harm of misdiagnosis can be extended by lack of clinician recognition and acceptance of the error when a patient raises concerns. This news story shares the experience of a physician-patient whose recognition of a diagnostic mistake was initially dismissed. The author defines the repeated lack of organizational willingness to resolve the situation as a normalized deviance in health care.
Haslett JJ, Genadry L, Zhang X, et al. Stroke. 2019;50:2858-2864.
Delayed diagnosis and treatment are common patient safety issues with significant adverse outcomes for patients. Analyzing nearly 300 medical malpractice cases related to acute care of stroke patients, this review found that the majority of malpractice lawsuits alleged failure of timely diagnosis and treatment. The majority of cases resulted in no payout, but those that did result in payout saw an average settlement in excess of $1.8 million in settlements and $9.7 million in plaintiff verdicts. 
Armstrong D. ProPublica. August 23, 2019.
Implicit biases can affect communication, diagnosis, and treatment decisions. This news article reports the experience of a neurologist and the biases that negatively influenced her health care, such as lack of respect for women presenting with functional symptoms and premature closure.
An elderly man admitted for agitation and suicidal ideation was prescribed clozapine by psychiatry. The clozapine Risk Evaluation and Mitigation Strategy (REMS) program requires both prescribers and patients to be registered in an online database. A REMS-registered attending psychiatrist entered the initial order (12.5 mg). During the hospitalization, the medicine intern, who was not registered with the REMS program, titrated the dose to 25 mg daily and also wrote the discharge prescription.
Iezzoni LI. The New England journal of medicine. 2019;380:2092-2093.
This commentary describes an incident involving diagnostic error and substandard care of a patient with disability. The author cautions against assumptions about individuals with disabilities that can compromise care. A PSNet commentary discussed the impact of diagnostic overshadowing on patient care.
Kaisey M, Solomon AJ, Luu M, et al. Multiple sclerosis and related disorders. 2019;30:51-56.
This retrospective study of patients with a diagnosis of multiple sclerosis found that nearly 20% had been misdiagnosed and did not have the disease. The authors highlight the risks from misdiagnosis including exposure to high-risk medications with resultant adverse drug events and delay in correct treatment for patient conditions.
Fitzsimons BT, Fitzsimons LL, Sun LR. Pediatrics. 2019;143(4):e20183458.
Rare diseases pose diagnostic challenges for physicians. This commentary offers insights from parents of a young child who died due to a delayed stroke diagnosis as well as from the patient's neurologist to raise awareness of childhood stroke and discuss the importance of partnership to heal from loss and advocate for improvement.
A woman was admitted to a hospital's telemetry floor for management of uncontrolled hypertension and palpitations. On the first hospital day, she complained of right arm numbness and weakness and had new difficulty answering questions. The nurse called the hospitalist and relayed the arm symptoms, but not the word-finding difficulty. The hospitalist asked the nurse to call for a neurology consultation. Four hours later, the patient's weakness had progressed; she was now completely unable to move her right arm.
Early in the academic year, interns were on their first day of a rotation caring for an elderly man hospitalized for a stroke, who had developed aspiration pneumonia and hypernatremia. When the primary intern signed out to the cross-cover intern, he asked her to check the patient's sodium level and replete the patient with IV fluids if needed. Although the cross-covering intern asked for more clarification, the intern signing out assured her the printed, written signout had all the information needed.
Mantri S, Fullard M, Gray SL, et al. JAMA neurology. 2019;76:41-49.
This analysis of Medicare claims data found a significant prevalence of concurrent use of dementia medication with acetylcholinesterase inhibitors and anticholinergic medications. This medication combination is a frank medical error that the authors describe as a never event. Despite this, coprescription occurred in 44% of those prescribed dementia medication, and this medication error was more common in the southeastern and midwestern regions of the United States compared to the northeast or western regions.
Kristensen RU, Nørgaard A, Jensen-Dahm C, et al. J Alzheimers Dis. 2018;63(1):383-394.
Prior research has shown that polypharmacy in elderly patients with dementia is associated with a greater risk of functional decline. This cross-sectional study of Danish patients age 65 and older found that polypharmacy and potentially inappropriate medication use were common in this population and were more frequent among patients with dementia.
Brought to the emergency department after being found unresponsive, an older man was given systemic thrombolytics to treat a suspected stroke. After administering the medication, the nurse noticed patches on the patient's back. The patient's wife explained that the patches, which contained fentanyl and whose doses had recently been increased, were for chronic back pain. In fact, the wife had placed two patches that morning. Medication reconciliation revealed that the patient had inadvertently received 3 times his previous dose. He was administered naloxone to treat the opioid overdose.
Amjad H, Roth DL, Sheehan OC, et al. Journal of general internal medicine. 2018;33:1131-1138.
This observation study found that patients who met criteria for dementia using objective assessments often lacked a formal dementia diagnosis, even when they regularly received medical care. Many patients who were diagnosed with dementia were not aware of their diagnosis. These results indicate the need to improve both diagnosis of dementia and communication regarding dementia diagnosis.