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1 - 11 of 11
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.

Diagnosis (Berl)2020;7(4):345-411.

COVID-19 is a novel coronavirus that harbors a variety of diagnostic, treatment, and management hurdles. This special issue covers a variety of clinical topics including optimal diagnostic methods, near misses, and diagnostic accuracy.   

After a failed induction at 36 weeks, a 26-year-old woman underwent cesarean delivery which was complicated by significant postpartum hemorrhage. The next day, the patient complained of severe perineal and abdominal pain, which the obstetric team attributed to prolonged pushing during labor. The team was primarily concerned about hypotension, which was thought to be due to hypovolemia from peri-operative blood loss. After several hours, the patient was transferred to the medical intensive care unit (ICU) with persistent hypotension and severe abdominal and perineal pain. She underwent surge

This Primer provides an overview of the history and current status of the patient safety field and key definitions and concepts. It links to other Patient Safety Primers that discuss the concepts in more detail.
Koo A, Smith JT. Insights Imaging. 2019;10:68.
Prior research has examined what factors may influence learning from mistakes. Researchers describe their analysis of more than 600 cases discussed at educational radiology conferences over several years. They were able to identify numerous opportunities for improving learning from error, including using positive cases (e.g., near misses or difficult cases in which extra effort helped avert an error) and targeting teaching to address recurrent deficiencies.
Steelman VM, Williams TL, Szekendi MK, et al. Arch Pathol Lab Med. 2016;140:1390-1396.
Errors related to the handling of surgical specimens can lead to serious patient harm in the form of delayed and missed diagnoses as well as repeat procedures. In this retrospective review, researchers looked at 648 reported adverse events and near misses involving surgical specimen management. They found that all steps of the specimen handling process are subject to error, but specimen labeling, collection, and transport represented the most frequently reported incidents. Additionally, 52 of the events led to the need for further treatment or to patient harm. The authors suggest that to enhance the safety of specimen handling, organizations should develop standard processes, provide training for staff, improve communication and handoffs, and consider the use of technological systems that might facilitate tracking of specimens.
Sadigh G, Loehfelm T, Applegate KE, et al. AJR Am J Roentgenol. 2015;205:337-43.
Despite The Joint Commission requirement to use at least two patient identifiers when obtaining an imaging study, wrong-patient events still occur. This retrospective case review study determined the prevalence of reported near-miss wrong-patient events in radiology at two large academic hospitals. The overall event rate was 4 per 100,000 radiology studies.
Ogdie AR, Reilly JB, Pang WG, et al. Acad Med. 2012;87:1361-7.
Diagnostic errors have been described as the next frontier in patient safety. Cognitive biases are common causes for these errors but have remained an elusive target for medical educators. This study describes an educational intervention for internal medicine residents consisting of reflective writing and facilitated small group discussions about personal experiences with diagnostic errors. Participating residents identified at least one cognitive bias and one contextual factor that may have contributed to their error. The most frequently implicated biases were anchoring and availability. Most residents also described a strategy to prevent similar errors in the future. A near miss stemming from an initial diagnostic error is highlighted in an AHRQ WebM&M commentary.
A man presented to the emergency department (ED) complaining of knee problems, and the triage nurse wrote down the chief complaint as "bilateral knee pain." The ED physician diagnosed a musculoskeletal injury and prepared to discharge him, but the patient was noticeably unsteady. Further examination and imaging revealed a subdural hematoma requiring urgent neurosurgical intervention.
Dunn WF, Adams SC, Adams RW. Chest. 2008;133:1217-20.
This case report describes how diagnostic and medication errors led to a temporary coma. The article features the views of both the patient and her husband, and an accompanying editorial discusses disclosing errors to patients.