Narrow Results Clear All
- Communication Improvement
- Education and Training 3
- Error Reporting and Analysis 7
- Legal and Policy Approaches 1
- Logistical Approaches 2
- Quality Improvement Strategies 5
- Technologic Approaches 4
- Device-related Complications 1
- Diagnostic Errors
- Discontinuities, Gaps, and Hand-Off Problems 2
- Fatigue and Sleep Deprivation 1
- Identification Errors 2
- Medical Complications 4
- Medication Safety 1
- Nonsurgical Procedural Complications 1
- Psychological and Social Complications 1
- Surgical Complications 1
- Internal Medicine 8
- Surgery 1
- Palliative Care 1
Search results for ""
Cases & Commentaries
- Web M&M
Tejal K. Gandhi, MD, MPH; October 2003
Switched urine specimens lead to a patient receiving the wrong answer about her pregnancy test.
Cases & Commentaries
- Spotlight Case
- Web M&M
Elizabeth B. Lamont, MD, MS; September 2004
Following hernia repair surgery, an elderly woman is incidentally found to have a mass in her neck. Expecting the worst, the treating physician recommends palliative care and withdrawal of mechanical ventilation, before biopsy results are in.
Davis R. USA Today. October 25, 2006.
This article shares stories of missed heart attack diagnoses and is accompanied by an online poll for readers to share their experiences with medical error.
Holt TE. Men's Health. November 3, 2006.
This series includes articles on "doorway diagnosis" (or a doctor's assessment of a patient before an exam begins), anesthesiologists addicted to painkillers, and medical mistakes in the emergency room.
Zimmerman R. Wall Street Journal. February 6, 2007:A1.
This article reports on a mother's campaign to educate parents about kernicterus and to make bilirubin tests standard for all newborns.
St. Paul, MN: Minnesota Department of Health; January 2009.
This report provides background on the Minnesota Never Events reporting initiative, tips for patients on how to receive the safest care possible, and a table of events reported by all hospitals in the state.
"The Colbert Report." Comedy Central. March 19, 2007.
Stephen Colbert interviews Dr. Jerome Groopman about diagnostic errors in medicine and his new book, "How Doctors Think."
Sanders L. New York Times Magazine. April 22, 2007:28, 30.
A physician shares her experience with failing to diagnose a patient's prostate problems.
Rifkin D. New York Times. November 16, 2009;Science Desk:5.
Reporting on cases of miscommunication and missed diagnosis, this news column illustrates how strictly following quality improvement procedures might lead providers to ignore important contextual information—from patients—that also contributes to safe care.
Boodman SG. Washington Post. June 13, 2011:E1.
Olsen D. State Journal-Register. June 26, 2011.
This newspaper article discusses a case of diagnostic error, explores the complexity of the diagnostic process, and provides tips to help patients avoid such errors.
Fischer MA. AARP The Magazine. July/August 2011;54:50-53,80.
This magazine article discusses several cases of misdiagnosis, explores reasons for errors, and provides tips for patients to improve safety.
Groopman J. Boston, MA: Houghton Mifflin; 2007. ISBN: 0618610030.
In this book, the author presents several stories that illustrate the forces that shape physician decision-making and may lead to diagnostic mistakes. Borrowing from the field of cognitive psychology, a number of errors stemming from clinicians' use of heuristics, or ''rule of thumb'' shortcuts, are highlighted. This book introduced these concepts on a popular level to many clinicians and the public. The book also discusses the role patients can play to minimize these mistakes. A prior AHRQ WebM&M perspective discussed diagnostic errors and provided advice for reducing cognitive slips.
Journal Article > Study
Meyer AND, Longhurst CA, Singh H. J Med Internet Res. 2016;18:e12.
The frequency of missed and delayed diagnoses is stimulating interest in innovative ways of improving the diagnostic process. This study reports on the initial experience of a crowdsourcing approach to diagnosis. Patients with difficult-to-diagnose symptoms accessed an online program where volunteer case solvers—only 58% of whom worked in medicine in any capacity—engaged in discussion with patients and provided diagnostic suggestions. A majority of patients felt the service was useful and about half would recommend the program.
Innes S. Arizona Daily Star. September 12, 2016.
Delayed diagnoses can have serious consequences. This news article reviews several examples of misdiagnosis and insights from the patients and families involved, explores the importance of engaging patients in determining correct diagnoses, and places the discussion in the broader context of efforts to reduce diagnostic error.
CDC Vital Signs. August 23, 2016.
Boodman SG. Washington Post. December 4, 2016.
Delays in diagnosis can both diminish the patient–physician relationship and result in harm. This newspaper article describes steps patients can take to enable effective diagnosis, including reviewing their medical records, asking questions during discussions with clinicians, and bringing an advocate to appointments.
Kast S. "On the Record." WYPR. October 31, 2017.
Diagnostic error continues to motivate improvement efforts in patient safety. This audio news segment discusses challenges that contribute to misdiagnosis, strategies to prevent diagnostic errors, and recommendations for patients to reduce risks such as preparing for appointments and asking questions.
Peskin SM. New York Times. October 4, 2018.
Error disclosures are difficult but important conversations that can have negative consequences for patients, clinicians, and organizations, even when they are done appropriately. This newspaper article offers insights from a doctor who experienced both sides of disclosure, as a physician disclosing an error and as a patient whose physician missed a complication, and discusses how to manage relationships once clinical mistakes are recognized.
Journal Article > Study
Patient groups, clinicians and healthcare professionals agree—all test results need to be seen, understood and followed up.
Dahm MR, Georgiou A, Herkes R, et al. Diagnosis (Berl). 2018;5:215-222.
Inadequate test result follow-up places patients at risk of delayed diagnosis, especially in the ambulatory setting. Diverse stakeholders in Australia established an agenda for enhancing test result management, which included better governance, improved use of technology, and consistent patient engagement. A WebM&M commentary explored two incidents where poor test result follow-up led to patient harm.