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Search results for "Health Care Executives and Administrators"

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  • Health Care Executives and Administrators
  • Neurology
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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 > Study

Weekly variation in health-care quality by day and time of admission: a nationwide, registry-based, prospective cohort study of acute stroke care.

Bray BD, Cloud GC, James MA, et al; SSNAP collaboration. Lancet. 2016;388:170-177.

The weekend effect—worse outcomes for patients admitted on weekends compared to weekdays—has been demonstrated in studies of several common conditions requiring hospital care. The mechanism for this effect remains undefined. This study of acute stroke admissions in the United Kingdom identifies several aspects of temporal variation in care quality. These included diurnal pattern (variation by the time of day at which patients were admitted) and a day of the week pattern (variation by the day on which patients were admitted, independent of weekend versus weekday). The results of this study indicate that the notion of a weekend effect may be an oversimplification.

Journal Article > Study

Medical costs of Alzheimer's disease misdiagnosis among US Medicare beneficiaries.

Hunter CA, Kirson NY, Desai U, Cummings AK, Faries DE, Birnbaum HG. Alzheimers Dement. 2015;11:887-895.

Diagnostic errors are moving toward the forefront of patient safety. This study analyzed Medicare patients that were initially misdiagnosed as having Alzheimer disease prior to their diagnosis of vascular dementia or Parkinson disease. These patients used more medical services, costing approximately $9,500 to $14,000 more each year, up until the time of their correct diagnosis.

Cases & Commentaries

Privacy or Safety?

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

John D. Halamka, MD, MS, and Deven McGraw, JD, MPH, LLM; July/August 2015

A hospitalized patient with advanced dementia was to undergo a brain MRI as part of a diagnostic workup for altered mental status. Hospital policy dictated that signout documentation include only patients' initials rather than more identifiable information such as full name or birth date. In this case, the patient requiring the brain MRI had the same initials as another patient on the same unit with severe cognitive impairment from a traumatic brain injury. The cross-covering resident mixed up the two patients and placed the MRI order in the wrong chart. Because the order for a "brain MRI to evaluate worsening cognitive function" could apply to either patient, neither the bedside nurse nor radiologist noticed the error.

Journal Article > Commentary

Opioids for chronic noncancer pain: a position paper of the American Academy of Neurology.

Franklin GM. Neurology. 2014;83:1277-1284.

Risk associated with the opioid use has been identified as a growing patient safety concern in the United States. This position paper describes why this problem is emerging, reviews evidence and policy to guide safe opioid prescribing for pain management, and includes recommendations for neurologists to reduce the likelihood of adverse events involving these high-risk medications, such as improved prescription monitoring.

Newspaper/Magazine Article

Preventing medical errors: how to proceed with caution.

Shaw G. Hearing J. July 2014;67:11,14-16.

This article provides an overview of patient safety issues in audiology such as diagnostic error and incomplete documentation. The author reviews steps individual clinicians can take to respond to errors and malpractice claims.

Journal Article > Commentary

Redesigning surgical decision making for high-risk patients.

Glance LG, Osler TM, Neuman MD. N Engl J Med. 2014;370:1379-1381.

Discussing communication weaknesses in surgery, this commentary examines how team-based decision making can contribute to safer and more patient-centered care in this setting, particularly for complex cases. The authors advocate for an enhanced safety culture to support better communication.

Journal Article > Study

Missed diagnosis of stroke in the emergency department: a cross-sectional analysis of a large population-based sample.

Newman-Toker DE, Moy E, Valente E, Coffey R, Hines AL. Diagnosis. 2014;1:155-166.

This observational study identified patients who visited the emergency department within 30 days prior to a stroke diagnosis. Nearly 13% of patients had a potential missed diagnosis, and more than 1% had a probable missed diagnosis of stroke. This study illustrates a novel approach to characterizing the incidence of missed diagnosis, an important and understudied patient safety problem.

Journal Article > Study

Early access to a neurologist reduces the rate of missed diagnosis in young strokes.

Mohamed W, Bhattacharya P, Chaturvedi S. J Stroke Cerebrovasc Dis. 2013;22:e332-e337.

Diagnosing acute stroke in young patients is notoriously challenging. This retrospective study found fewer missed diagnoses and greater use of appropriate initial therapies in patients who were initially evaluated at hospitals with a neurology residency program.

Cases & Commentaries

From Possible to Probable to Sure to Wrong—Premature Closure and Anchoring in a Complicated Case

  • Web M&M

David E. Newman-Toker, MD, PhD; April 2013

Admitted to the hospital with headache and word-finding difficulties, a man was given a preliminary diagnosis of vasculitis. Although serial imaging studies seemed to indicate progression of his brain lesions, these were not biopsied and discovered to be glioblastoma multiforme until 4 months later. The delay in diagnosis contributed to his rapid clinical decline.

Journal Article > Commentary

"Just like EKGs!" Should EEGs undergo a confirmatory interpretation by a clinical neurophysiologist?

Benbadis SR. Neurology. 2013;80(suppl 1):S47-S51.

This commentary discusses how misinterpretation of electroencephalograms (EEGs) can lead to misdiagnosis of epilepsy and describes methods to prevent these incidents, such as mandatory EEG training during neurology residency.

Perspectives on Safety > Perspective

Quality and Safety Challenges in Critical Care: Preventing and Treating Delirium in the Intensive Care Unit

with commentary by Eduard E. Vasilevskis, MD; E. Wesley Ely, MD, MPH; Robert S. Dittus, MD, MPH, Delirium as a Safety Target, December 2012

This piece details a number of evidenced-based practices to help detect, prevent, and treat delirium, which is now seen as a patient safety hazard.

Cases & Commentaries

Misleading Complaint

  • Web M&M

Krishan Soni, MD, MBA, and Gurpreet Dhaliwal, MD; July 2012

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.

Cases & Commentaries

The Perils of Cross Coverage

  • Spotlight Case
  • Web M&M

Jeanne M. Farnan, MD, MHPE; and Vineet M. Arora, MD, MAPP; May 2012

Inadequate signout to the members of the night float team prevented them from appreciating a patient's mental status changes. Found comatose by the weekend cross-coverage team, the patient had a prolonged ICU stay.

Cases & Commentaries

More Treatment—Better Care?

  • Web M&M

Rita Redberg, MD, MSc; December 2011

A patient with Guillain-Barré syndrome received more than the recommended number of plasmapheresis treatments. When the ordering physicians were asked why so many treatments were given, they both responded that the patient was improving so they felt that more treatments would help him recover even more.

Journal Article > Study

Comprehensive stroke centers overcome the weekend versus weekday gap in stroke treatment and mortality.

McKinney JS, Deng Y, Kasner SE, Kostis JB; Myocardial Infarction Data Acquisition System (MIDAS 15) Study Group. Stroke. 2011;42:2403-2409.

This study found that stroke patients were more likely to die if admitted on a weekend, as has also been found with myocardial infarctions. However, patients admitted to a specialized stroke center had equivalent outcomes regardless of weekend or weekday admission.

Cases & Commentaries

Patient Safety and Adherence to Self-Administered Medications

  • Web M&M

Harriette Gillian Christine Van Spall, MD; Robby Nieuwlaat, PhD; and R. Brian Haynes, MD, PhD; July 2011

A man with HIV disease and a recent diagnosis of CNS toxoplasmosis presented to the ED for the third time in two weeks with headaches, seizures, and right-sided weakness. Physicians pursued a workup for treatment-resistant toxoplasmosis or another brain disease, but discovered that the patient had run out of his toxoplasmosis medications.

Cases & Commentaries

Duty to Disclose Someone Else's Error?

  • Spotlight Case
  • Web M&M

Thomas H. Gallagher, MD; May 2011

Transferred to a tertiary hospital, a child with severe swelling of the brain is found to have venous sinus thromboses and little chance of survival. Further review revealed that the referring hospital had missed subtle signs of cerebral edema on the initial CT scan days earlier, raising the question of whether to disclose the errors of other facilities or caregivers.

Press Release/Announcement

Morphine sulfate oral solution 100 mg per 5 mL (20 mg/mL): medication use error—reports of accidental overdose.

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; January 10, 2011.

This announcement reveals a labeling change to reduce the potential for misadministration of a pain medication.

Newspaper/Magazine Article

NFL concussions and common sense: a recipe for medical errors and a lesson for physician leaders.

Lazarus A. Physician Exec. Jan-Feb 2011;37:6-9.

This magazine article discusses factors that contribute to misdiagnosis in football players and suggests system changes address such errors.

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