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- Diagnostic Errors
- Discontinuities, Gaps, and Hand-Off Problems 11
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Search results for "Patients"
- Diagnostic Errors
Shell ER. Sci Am. 2015;313(5):28-29.
Journal Article > Study
A patient-initiated voluntary online survey of adverse medical events: the perspective of 696 injured patients and families.
Southwick FS, Cranley NM, Hallisy JA. BMJ Qual Saf. 2015;24:620-629.
This study analyzed data from an internet-based reporting system that enabled patients and families to describe adverse events. Respondents reported missed and delayed diagnoses, treatment errors, procedural complications, health care–associated infections, and adverse drug events. Most participants did not experience prompt error disclosure but instead faced a denial of responsibility and secretive behavior, which they related to subsequent mistrust. To prevent adverse events, patients and family members suggested using systems approaches (such as universal handwashing and other infection control measures), improving care transitions between providers, ensuring supervision of trainees, and partnering with patients and families for shared decision-making. These findings underscore the importance of error disclosure, effective communication, and allowing patients to report adverse events in order to enhance safety.
Overkill: An avalanche of unnecessary medical care is harming patients physically and financially. What can we do about it?
Gawande A. New Yorker. May 11, 2015.
The overuse of medical care and its negative impact on personal health and finances is an emerging concern. This magazine article provides insights from a surgeon about how providing unnecessary care can contribute to patient harm and waste. Consequences of unneeded medical care include overtesting, overdiagnosis, and overtreatment. A previous AHRQ WebM&M perspective explored overuse as a patient safety problem.
Cohn J. The Atlantic. March 2013;311:59–67.
This magazine article reports how technology, such as IBM's Watson, can improve the efficiency and accuracy of health care decision making.
Sanders L. New York Times Magazine. March 18, 2012.
This interactive magazine feature takes readers through the decision-making process in a case involving diagnostic error.
Boodman SG. Washington Post. June 13, 2011:E1.
Tampa, FL: Sepsis Alliance; 2010.
Revealing incidents in which diagnostic delay led to sepsis, this video provides information to help consumers recognize the condition.
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.
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.
Journal Article > Study
Cohn F, Rudman WJ. Jt Comm J Qual Saf. 2004;30:636-646.
National Quality Forum.
Panner M. Forbes. August 12, 2019.
Diagnostic errors can result in harm across the spectrum of practice. Discussing cognitive and system factors in radiology that contribute to diagnostic mistakes, this magazine article recommends ways to reduce risk of errors, including peer review of practice, structured reporting, and artificial intelligence–enabled decision support.
Journal Article > Study
Shen C, Nguyen M, Gregor A, Isaza G, Beattie A. JAMA Ophthalmol. 2019;137:690-692.
This study entered 42 validated clinical vignettes for eye diseases into an online symptom checker. As with prior studies, the performance of the online symptom checker in producing the correct diagnosis was suboptimal. The authors suggest that current performance of symptom checkers is not sufficient for timely and accurate diagnosis of ophthalmologic conditions.
Cullen A. Uitgeverij van Brug: The Hague, The Netherlands; 2019. ISBN: 9789065232236.
Patient stories offer important insights regarding the impact medical errors have on patients and their families. This book shares the author's experience with medical error and spotlights how lack of transparency in European health care can contribute to avoidable process failures that result in patient harm.
Topol E. New York, NY: Basic Books; 2019. ISBN: 978-1541644632.
This book explores how advancements in technology can improve decision making but may also diminish patient-centered care. The author discusses the potential of big data, artificial intelligence, and machine learning to enhance diagnosis and care delivery. A past PSNet interview with the author, Eric Topol, talked about the role of patients in the new world of digital health care.
Chisholm P. Health Shots. National Public Radio. February 27, 2019.
Park A. Time Magazine. January 24, 2019.
This news article reports on the documentary To Err Is Human, which was produced and directed by the son of patient safety leader Dr. John M. Eisenberg. The film is structured around patient safety advocate Sue Sheridan's experience with diagnostic errors that resulted in harm for both her son and husband. It features a wide range of experts who discuss the impact of error on all involved, the role of culture in facilitating both mistakes and progress, and why continued work in health care safety is needed.
Canadian Patient Safety Institute. October 2018.
Palo Alto, CA: Gordon and Betty Moore Foundation; November 1, 2018.
Missed or delayed diagnoses lead to delays in care and significant preventable harm for patients. Despite an increasing focus on diagnostic error, accurate measurement and implementation of effective strategies for mitigating its adverse effects remain challenging. The Gordon and Betty Moore Foundation recently announced a new $85 million initiative focused on diagnostic excellence that takes into account health care costs, timeliness, and individual patient needs. This initiative will focus on three clinical areas including cancer, infections, and cardiovascular events. Through this funding, the foundation hopes to stimulate novel approaches to measuring diagnostic performance and plans to assess the effectiveness of new technologies in improving the diagnostic process. A PSNet perspective highlighted ongoing challenges related to diagnostic error.
Web Resource > Multi-use Website
Australian National Health and Medical Research Council.
Overdiagnosis and the subsequent overuse of medical care contributes to unnecessary financial, psychological, and physical risk to patients. This research collaborative draws from expertise and experience from organizations in Australia investigating the problem of overdiagnosis and testing solutions to prevent medical care overuse.