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Search results for "Health Care Executives and Administrators"
- Cognitive Errors ("Mistakes")
- Diagnostic Errors
- Health Care Executives and Administrators
- Infectious Diseases
Journal Article > Commentary
Graber ML, Berg D, Jerde W, Kibort P, Olson APJ, Parkash V. Diagnosis (Berl). 2018;5:257-266.
This commentary provides a clinical review of a missed diagnosis of Epstein-Barr virus infection that was identified via autopsy and summarizes contributing factors to the incident with an emphasis on the role of cognitive bias. The piece includes the perspectives of the patient's family and from the organization regarding what happened and what could have been done to prevent this outcome. This discussion is the first in a series of diagnostic error case presentations to be published in this journal.
The Texas Health Presbyterian Hospital Ebola Crisis: A Perfect Storm of Human Errors, System Failures and Lack of Mindfulness.
Anderson-Fletcher E, Vera D, Abbott J. Houston, TX: Hobbs Center for Public Policy, University of Houston; 2015.
The high-profile misdiagnosis of a patient with Ebola in the United States serves as a key example of how system factors can contribute to diagnostic error. This analysis of the incident breaks down what happened and explores how attention to mindfulness and organizational culture can improve the safety of care processes.
Journal Article > Study
Filice GA, Drekonja DM, Thurn JR, Hamann GM, Masoud BT, Johnson JR. Infect Control Hosp Epidemiol. 2015;36:949-956.
Overuse of antibiotics is a major factor in the development of certain types of health care–associated infections. This retrospective study found that unnecessary antibiotic use was often a result of diagnostic error, particularly in patients who were empirically treated for urinary tract infections without clear diagnostic evidence. The results of this study imply that addressing diagnostic uncertainty should be a component of antimicrobial stewardship programs.
Journal Article > Study
Readmission after delayed diagnosis of surgical site infection: a focus on prevention using the American College of Surgeons National Surgical Quality Improvement Program.
Gibson A, Tevis S, Kennedy G. Am J Surg. 2014;207:832-839.
The National Surgical Quality Improvement Program (NSQIP) was developed to monitor and enhance the quality of surgical care. This retrospective study used the NSQIP indicators to identify cases of surgical site infections. Researchers found that nearly 50% of patients were diagnosed following hospital discharge, and many of these infections led to readmissions. Patients who presented with a surgical site infection after discharge were less likely to smoke or have chronic cardiopulmonary illness. The authors suggest that closer postdischarge follow-up might have prevented some readmissions they identified. However, prior studies did not show a benefit to early follow-up. A past AHRQ WebM&M commentary discussed environmental safety in the operating room and its relationship to surgical site infections.