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Search results for "Active Errors"

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Meeting/Conference > District of Columbia Meeting/Conference

Improving Diagnosis in Health Care: An Implementation Workshop.

The National Academies of Sciences, Engineering, and Medicine. July 17, 2017; National Academy of Sciences Building, Washington, DC.

Diagnostic error gained recognition as a patient safety concern with the publication of the Improving Diagnosis in Health Care report in 2015. This workshop will discuss progress since the report's release and review strategies for building on those successes to reduce diagnostic error.

Cases & Commentaries

Diagnostic Overshadowing Dangers

  • Web M&M

Maria C. Raven, MD, MPH, MSc; June 2017

Presenting with pain in her epigastric region and back, an older woman with a history of opioid abuse had abnormal vital signs and an elevated troponin level. Imaging revealed multiple spinal fractures and cord compression. Neurosurgery recommended conservative management overnight. However, her troponin levels spiked, and an ECG revealed myocardial infarction.

Patient Safety Primers

Patient Safety 101

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.

Cases & Commentaries

The Perils of Contrast Media

  • Spotlight Case
  • CME/CEU
  • Web M&M

Umar Sadat, MD, PhD, and Richard Solomon, MD; June 2017

To avoid worsening acute kidney injury in an older man with possible mesenteric ischemia, the provider ordered an abdominal CT without contrast, but the results were not diagnostic. Shortly later, the patient developed acute paralysis, and an urgent CT with contrast revealed blockage and a blood clot.

Journal Article > Commentary

Challenges and opportunities from the Agency for Healthcare Research and Quality (AHRQ) research summit on improving diagnosis: a proceedings review.

Henriksen K, Dymek C, Harrison MI, Brady JP, Arnold SB. Diagnosis. 2017 May 23; [Epub ahead of print].

Diagnostic error gained recognition as a patient safety concern with the publication of the Improving Diagnosis in Health Care report. This commentary reviews insights shared at a conference convened to discuss issues associated with diagnosis, including the need for concrete definitions of diagnostic error, the role of technology in improvement, and organizational factors that contribute to the problem.

Newspaper/Magazine Article

The last person you'd expect to die in childbirth.

Martin N, Montagne R. ProPublica and National Public Radio. May 12, 2017.

Maternal mortality is increasing in the United States. This news article reports on this critical safety problem in the context of the preventable death of a patient whose diagnosis of preeclampsia was missed by her providers, despite persistent concerns raised by family about the patient's symptoms.

Journal Article > Commentary

Farewell to a cancer that never was.

Lyon J. JAMA. 2017;317:1824-1825.

Overdiagnosis can result in financial, psychological, and physical harm for patients. This commentary discusses the reclassification of a subtype of thyroid cancer as a nonmalignancy and the impact changing guidelines can have on patients.

Journal Article > Commentary

An innovative collaborative model of care for undiagnosed complex medical conditions.

Nageswaran S, Donoghue N, Mitchell A, Givner LB. Pediatrics. 2017;139:e20163373.

Lack of collaboration among the clinical team can contribute to diagnostic problems. This commentary describes a collaborative model of care developed to enhance interdisciplinary teamwork across health care settings as a strategy to augment diagnosis for children with undiagnosed complex medical conditions.

Cases & Commentaries

Diagnostic Delay in the Emergency Department

  • Spotlight Case
  • CME/CEU
  • Web M&M

Kyle Marshall, MD, and Hardeep Singh, MD, MPH; May 2017

Emergency department evaluation of a man with morbid obesity presenting with abdominal pain revealed tachycardia, hypertension, elevated creatinine, and no evidence of cholecystitis. Several hours later, the patient underwent CT scan; the physicians withheld contrast out of concern for his acute kidney injury. The initial scan provided no definitive answer. Ultimately, physicians ordered additional CT scans with contrast and diagnosed an acute aortic dissection.

Cases & Commentaries

Hemolysis Holdup

  • Web M&M

Christopher M. Lehman, MD; May 2017

In the emergency department, an older man with multiple medical conditions was found to have evidence of acute kidney injury and an elevated serum potassium level. However, the blood sample was hemolyzed, which can alter the reading. Although the patient was admitted and a repeat potassium level was ordered, the physician did not institute treatment for hyperkalemia. Almost immediately after the laboratory called with a panic result indicating a dangerously high potassium level, the patient went into cardiac arrest.

Journal Article > Study

Extent of diagnostic agreement among medical referrals.

Van Such M, Lohr R, Beckman T, Naessens JM. J Eval Clin Pract. 2017 Apr 4; [Epub ahead of print].

Diagnostic uncertainty is common and can lead to missed or delayed diagnoses. This retrospective medical record review study examined cases where primary care providers sought diagnostic input from subspecialists. Investigators compared the final diagnosis from the subspecialty visit with the presumed diagnosis at the time of the initial subspecialty referral. They found that the diagnosis differed substantially in about one-fifth of cases following the subspecialty consultation. Costs were higher for cases with substantively different diagnoses compared to cases where subspecialists confirmed or further clarified diagnoses. The authors conclude that subspecialty access is critical to timely and accurate diagnosis. A recent WebM&M commentary discussed how cognition can influence diagnostic decision making.

Journal Article > Study

Pathologists' perspectives on disclosing harmful pathology error.

Dintzis SM, Clennon EK, Prouty CD, Reich LM, Elmore JG, Gallagher TH. Arch Pathol Lab Med. 2017;141:841-845.

Disclosure of medical errors is a recommended patient safety practice. This focus group study of pathologists found that most pathologists believe treating clinicians should disclose pathology errors and express concern that treating clinicians do not understand the inherent limitations of pathologic diagnosis. The authors suggest that developing consensus guidelines may improve disclosure of pathology errors.

Journal Article > Review

ED misdiagnosis of cerebrovascular events in the era of modern neuroimaging: a meta-analysis.

Tarnutzer AA, Lee SH, Robinson KA, Wang Z, Edlow JA, Newman-Toker DE. Neurology. 2017;88:1468-1477.

Delayed diagnosis of stroke can lead to preventable disability. This meta-analysis of diagnostic accuracy for cerebrovascular events in the emergency department found that overall 9% of strokes were misdiagnosed. The risk of misdiagnosis was higher if stroke symptoms were transient, nonspecific, or mild. The authors suggest that interventions to improve stroke diagnosis should focus on these specific disease presentations.

Journal Article > Study

Rates and characteristics of paid malpractice claims among US physicians by specialty, 1992–2014.

Schaffer AC, Jena AB, Seabury SA, Singh H, Chalasani V, Kachalia A. JAMA Intern Med. 2017;177:710-718.

This retrospective study of a claims database found that medical malpractice claims declined significantly between 1992 and 2014, but mean payment amounts increased at the same time. Diagnostic error was the overall most common reason for a claim, affirming the importance of improving diagnosis.

Journal Article > Commentary

Overcoming diagnostic errors in medical practice.

Bordini BJ, Stephany A, Kliegman R. J Pediatr. 2017 Mar 20; [Epub ahead of print].

This commentary describes a program developed to evaluate patients with undiagnosed and rare diseases as a way to reduce diagnostic error. The authors explain heuristic and clinical reasoning shortcomings that can hinder diagnosis and how to manage them through improved information gathering and hypothesis testing.

Audiovisual

The War on Error: Common Diagnostic Errors.

Medscape. 2016–2017.

Improving diagnosis has recently been recognized as a primary focus for patient safety. This collection highlights particular clinical areas of concern such as neurology and infectious disease. The articles offer expert commentary and review strategies to avoid common reasoning errors.

Journal Article > Commentary

A learning health care system using computer-aided diagnosis.

Cahan A, Cimino JJ. J Med Internet Res. 2017;19:e54.

Although advanced computing can assist in diagnosis, these systems are not routinely utilized. This commentary suggests a framework to develop diagnostic support technologies that capture physician knowledge to enhance diagnostic safety. The authors encourage drawing from crowdsourced data to guide improvements at a system level to address future practice and educational needs.

Cases & Commentaries

Consequences of Medical Overuse

  • Spotlight Case
  • CME/CEU
  • Web M&M

Daniel J. Morgan, MD, MS, and Andrew Foy, MD; March 2017

Brought to the emergency department from a nursing facility with confusion and generalized weakness, an older woman was found to have an elevated troponin level but no evidence of ischemia on her ECG. A consulting cardiologist recommended treating the patient with three anticoagulants. The next evening, she became acutely confused and a CT scan revealed a large intraparenchymal hemorrhage with a midline shift.

Cases & Commentaries

Correct Treatment Plan for Incorrect Diagnosis: A Pharmacist Intervention

  • Web M&M

Scott D. Nelson, PharmD, MS; March 2017

Although meningitis and neurosyphilis were ruled out for a woman presenting with a headache and blurry vision, blood tests returned indicating latent (inactive) syphilis. Due to a history of penicillin allergy, the patient was sent for testing for penicillin sensitivity, which was negative. The allergist placed orders for neurosyphilis treatment—a far higher penicillin dose than needed to treat latent syphilis, and a treatment regimen that would have required hospitalization. Upon review, the pharmacist saw that neurosyphilis had been ruled out, contacted the allergist, and the treatment plan was corrected.

Cases & Commentaries

Diagnosing a Missed Diagnosis

  • Web M&M

James B. Reilly, MD, MS, and Christopher Webster, DO; March 2017

A woman taking modified-release lithium for bipolar disorder was admitted with cough, slurred speech, confusion, and disorientation. Diagnosed with delirium attributed to hypercalcemia, she was treated with aggressive hydration. She remained disoriented and eventually became comatose. After transfer to the ICU, she was diagnosed with nephrogenic diabetes insipidus due to lithium toxicity.

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