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1 - 20 of 119

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.
Wiering B, Lyratzopoulos G, Hamilton W, et al. BMJ Qual Saf. 2022;31:579-589.
Delays in cancer diagnosis and treatment can lead to significant morbidity and mortality. This retrospective study linking data reflecting primary and secondary care as well as cancer registry data found that only 40% of patients presenting with common possible cancer features received an urgent referral to specialist care within 14 days. Findings revealed that a significant number of these patients developed cancer within one year. 

117th Congress 2d Session. June 21, 2022.

Strengthening diagnostic error research and training can lead to sustained diagnostic improvement. Expanding upon legislation introduced in 2020, the “Improving Diagnosis in Medicine Act of 2022” would establish research centers of diagnostic excellence, an interagency council on improving diagnosis in healthcare, and fellowship and training grants in diagnostic safety, as well as convene an expert panel on diagnostic error measurement and data collection and prioritize stakeholder engagement across all activities.
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.
Graber ML, Holmboe ES, Stanley J, et al. Diagnosis (Berl). 2022;9:166-175.
In 2019, a consensus group identified twelve competencies to improve diagnostic education. This article details next steps for incorporating competencies into interprofessional health education: 1) Developing a shared, common language for diagnosis, 2) developing the necessary content, 3) developing assessment tools, 4) promoting faculty development, and 5) spreading awareness of the need to improve education in regard to diagnosis.
Morsø L, Birkeland S, Walløe S, et al. Jt Comm J Qual Patient Saf. 2022;48:271-279.
Patient complaints can provide insights into safety threats and system weaknesses. This study used the healthcare complaints analysis tool (HCAT) to identify and categorize safety problems in emergency care. Most problems arose during examination/diagnosis and frequently resulted in diagnostic errors or errors of omission.
Shenoy A, Shenoy GN, Shenoy GG. Patient Saf Surg. 2022;16:10.
Defensive medicine refers to clinician behaviors with the intent to avoid malpractice risk due to care omissions. This article provides an overview of defensive medicine and its relationship to the taxonomies of medical errors and the risks that defensive medicine places on patients, hospital administrators, and systems, as well as clinicians.
Khoong EC, Sharma AE, Gupta K, et al. J Gen Intern Med. 2022;37:1270-1274.
In response to concerns about COVID-19 transmission, many ambulatory care visits have transitioned to telehealth visits. This commentary describes the impact of telehealth on diagnostic errors and medication safety in ambulatory settings. Recommendations to further understand the impact of telemedicine on patient safety include: systematically measuring patient safety outcomes and increasing reporting of safety incidents; identifying the patients and clinical scenarios with the greatest risk of unsafe telehealth care; identifying and supporting best practices to ensure equal access to safe telehealth.
Rosenkrantz AB, Siegal D, Skillings JA, et al. J Am Coll Radiol. 2021;18:1310-1316.
Prior research found that cancer, infections, and vascular events (the “big three”) account for nearly half of all serious misdiagnosis-related harm identified in malpractice claims. This retrospective analysis of malpractice claims data from 2008 to 2017 found that oncology-related errors represented the largest source of radiology malpractice cases with diagnostic allegations. Imaging misinterpretation was the primary contributing factor.

Kast S, Gerr M, Black D, et al. “On the Record.” WYPR. August 3, 2021

Misdiagnosis is a persistent challenge for patients and families to navigate. This audio news segment highlights one family's experience with poor care stemming from disrespect and premature closure that resulted in missed diagnosis, unnecessary care, and patient death. The story is coupled with a broader discussion on the extent of diagnostic errors and reasons they occur.
Sivarajah R, Dinh ML, Chetlen A. J Breast Imaging. 2021;3:221-230.
This article describes the Yorkshire contributory factors framework, which identifies factors contributing to safety errors across four hierarchical levels (active errors, situational factors, local working conditions, and latent factors) and two cross-cutting factors (communication systems and safety culture). The authors apply this framework to a case of missed mass on breast imaging and discuss how its use can help health systems effectively learn from error and develop systematic, proactive programs to improve safety and manage safety issues.
Cheraghi-Sohi S, Holland F, Singh H, et al. BMJ Qual Saf. 2021;30:977-985.
Diagnostic error continues to be a source of preventable patient harm. The authors undertook a retrospective review of primary care consultations to identify incidence, origin and avoidable harm of missed diagnostic opportunities (MDO). Nearly three-quarters of MDO involved multiple process breakdowns (e.g., history taking, misinterpretation of diagnostic tests, or lack of follow up). Just over one third resulted in moderate to severe avoidable patient harm. Because the majority of MDO involve several contributing factors, interventions, including policy changes, should be multipronged.

Cleghorn E. New York, NY: Dutton; 2021. ISBN: 9780593182956.

Women have been affected by implicit bias that undermines the safety of their care and trust in the medical system. This book shares the history anchoring the mindsets driving ineffective care for women and a discussion of the author’s long-term lupus misdiagnosis.
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.

Northwest Safety and Quality Partnership. June 22, 2021. 

Diagnostic radiology mistakes contribute to delays and ineffective treatments that contribute to patient harm. This webinar examined factors that contribute to errors in image interpretation and will highlight strategies to learn from those errors to improve diagnostic process reliability. Registering for the program provides access to the recording.

Medscape Medical News. May 12, 2021.

Delays and mistakes in health care for distinct patient populations hold improvement lessons for the broader system. This news story highlights problems in correctional system cancer diagnoses and treatment that may indicate other types of prison care delivery problems.
Johnson SM, Samulski TD, O’Connor SM, et al. Am J Clin Pathol. 2021;156:559-568.
Newly diagnosed cancer patients may request second opinions to confirm diagnosis, treatment, or prognosis. This study evaluated the pathology-specific reimbursement for cases originating at the primary site, a comprehensive cancer center, and cases originating at affiliate sites and referred to the cancer center for second opinions. Results confirmed that second opinions can reduce diagnostic errors and potentially lower costs of subsequent treatment; however, ways to improve the cost and process of receiving a second opinion should be explored.
Zhou Y, Walter FM, Singh H, et al. Cancers (Basel). 2021;13:156.
Delays in cancer diagnosis can lead to treatment delays and patient harm. This study linking primary care and cancer registry data found that more than one-quarter of bladder and kidney cancer patients presenting with fast-tract referral features did not achieve a timely diagnosis. These findings suggest inadequate adherence to guidelines intended to help identify patients with high risk of cancer based on the presence of alarm signs and symptoms.

Boodman SG. Washington Post. January 23, 2021.

Misdiagnosis can perpetuate over a long period and delay a correct course of treatment. This news feature shares an example of depression misdiagnosis that masked the true problem of a neurological tumor manifesting in what was seen and treated as a psychological condition.