Narrow Results Clear All
- Communication Improvement 11
- Culture of Safety 4
- Education and Training 7
- Error Reporting and Analysis 12
- Human Factors Engineering 1
- Legal and Policy Approaches 6
- Logistical Approaches 1
- Quality Improvement Strategies 8
- Specialization of Care 1
- Teamwork 2
- Technologic Approaches 5
- Transparency and Accountability 1
- Device-related Complications 1
- Diagnostic Errors
- Discontinuities, Gaps, and Hand-Off Problems 7
- Identification Errors 1
- Medical Complications 2
- Medication Safety 3
- Nonsurgical Procedural Complications 1
- Psychological and Social Complications 2
- Surgical Complications 3
- Internal Medicine 10
- Family Members and Caregivers 1
- Health Care Executives and Administrators 17
- Health Care Providers 22
- Non-Health Care Professionals 15
- Patients 8
Search results for "Diagnostic Errors"
- Diagnostic Errors
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.
Howard J. Cham, Switzerland: Springer Nature Switzerland; 2019. ISBN: 9783319932231.
Cognitive biases contribute to diagnostic missteps, delays, and errors. This publication uses case-based illustrations to explore the effect of common cognitive biases (e.g., confirmation, anchoring, and overconfidence) on care. The author suggests feedback, healthy skepticism, and open discussion as tactics to reduce errors stemming from bias in decision-making.
Partnership for Health IT Patient Safety. Plymouth Meeting, PA: ECRI; August 2018.
Inadequate follow-up of test results can contribute to missed and delayed diagnoses. Developing optimal test result management systems is essential for closing the loop so that results can be acted upon in a timely manner. The Partnership for Health IT Patient Safety convened a working group to identify how technology can be used to facilitate improved communication and timely action regarding test results. This report summarizes the methods used by the working group and their findings. Recommendations include improving communication by standardizing the format of test results, including required timing for diagnostic testing responses, automating the notification process in electronic health records, and optimizing alerts to reduce alert fatigue. A past WebM&M commentary discussed a case involving ambulatory test result management.
Dusenbery M. New York, NY: HarperOne; 2018. ISBN: 9780062470805.
Implicit biases can affect diagnostic decision-making. This book discusses biases and cultural limitations that influence the safety of women's health care. Systemic problems are highlighted, such as lack of respect for patient concerns and insufficient biomedical research examining treatments and their effect on women.
Institute for Healthcare Improvement, National Patient Safety Foundation. Cambridge, MA: Institute for Healthcare Improvement; 2017.
Missed and delayed diagnoses can stem from problems in the outpatient referral process. The Institute for Healthcare Improvement convened an expert panel aimed at addressing safety vulnerabilities in the current referral process. The report delineates nine steps in the referral process, starting from the primary care provider ordering the referral and ending with communication of the treatment plan to patients and families. Recommendations to improve this process include interoperability between primary care and subspecialty electronic health records, standardizing handoffs between providers, clear standards of accountability for patient follow-up, and use of evidence-based communication methods like teach-back with patients and families. The report concludes that prioritizing the safety of the referral process is important to reduce diagnostic errors.
Clearing the Error: Using Public Deliberation to Define Patient Roles as Partners in the Diagnostic Process.
St. Paul, MN: Society to Improve Diagnosis in Medicine, Maxwell School of Citizenship and Public Affairs at Syracuse University, and Jefferson Center; 2017.
Advocates for improving diagnosis emphasize the role of the patient as key to success. This report examines factors to consider when designing interventions to strengthen patient participation in the diagnostic process. Recommendations to enhance relationships with patients to reduce diagnostic error focus on managing misperceptions that can affect decision-making and communication.
Washington, DC: National Quality Forum. September 19, 2017.
Although diagnostic error is a well-recognized source of preventable patient harm, measuring and mitigating diagnostic error remains challenging. This National Quality Forum report describes the development of a framework to assist with measuring diagnostic quality and safety. The framework outlines 3 domains and 11 subdomains for measuring diagnostic quality and safety as well as 62 prioritized measure concepts. High-priority areas for measure development include timeliness of diagnosis, timely follow-up of test results, communication and handoffs, patient-reported diagnostic errors, and patient experience related to diagnostic care. The committee also identified several cross-cutting themes and makes recommendations for researchers seeking to develop measures to improve diagnostic safety. A PSNet perspective discussed challenges and opportunities regarding diagnostic error.
Croskerry P, Cosby K, Graber ML, Singh H. Boca Raton, FL: CRC Press; 2017. ISBN: 9781409432333.
Efforts to enhance the reliability of the diagnostic process must take various elements into consideration. This publication discusses diagnosis, the role of reasoning in the process, challenges to diagnostic effectiveness, and strategies to make diagnosis more reliable such as patient engagement and using information technology.
Chicago, IL: American Board of Medical Specialties; 2016.
In response to the 2015 Improving Diagnosis in Health Care report, the National Patient Safety Foundation and American Board of Medical Specialties convened a multidisciplinary panel of patient safety experts to determine safety challenges in the diagnostic process as a way to inform recommendations for improving diagnosis. Their consensus focused on educational, assessment, and cultural aspects of the process.
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.
Committee on Diagnostic Error in Health Care, National Academies of Science, Engineering, and Medicine. Washington, DC: National Academies Press; 2015.
The National Academy of Medicine (formerly the Institute of Medicine) launched the patient safety movement with the publication of its report To Err Is Human. The group has now released a report about diagnosis, which they describe as a blind spot in health care. Available evidence suggests that most Americans will experience a missed or delayed diagnosis in their lifetime. The committee made several recommendations to improve diagnosis, including promoting teamwork among interdisciplinary health care teams, enhancing patient engagement in the diagnostic process, implementing large-scale error reporting systems with feedback and corrective action, and improving health information technology (as recommended in prior reports). Longer-term recommendations include establishing a work system and safety culture that foster timely and accurate diagnosis, improving the medical liability system to foster learning from missed or delayed diagnoses, reforming the payment system to support better diagnosis, and increasing funding for research in diagnostic safety. The report emphasizes the need for much more effort, and far more resources, at the practice, policy, and research levels to address this pressing safety problem.
Visser SN, Zablotsky B, Holbrook JR, Danielson ML, Bitsko RH. Natl Health Stat Report. 2015;(81):1-8.
This survey of parents of children with attention-deficit/hyperactivity disorder examined how this diagnosis was established. There was variation in the diagnostic process, including testing methods and types of practitioners involved (primary care physician, psychologist, psychiatrist). These results demonstrate the inherent challenge of diagnosing a heterogeneous condition even when diagnostic guidelines and criteria exist.
Trowbridge RL Jr, Rencic JJ, Durning SJ, eds. Philadelphia, PA: American College of Physicians; 2015. ISBN: 9781938921056.
Hoffman J, ed. Cambridge, MA: CRICO Strategies; 2014.
This analysis of more than 4700 diagnosis-related malpractice claims found that most errors occur in the ambulatory setting, involve lapses in clinical judgement, and result in missed diagnosis of cancer. The authors use the data to explore cognitive and process failures that contributed to diagnostic errors.
Boston, MA: Harvard School of Public Health; December 2014.
This statewide public telephone survey in Massachusetts found that more than 20% of respondents experienced a medical error in the prior 5 years, and more than half of these incidents resulted in harm. Prior patient surveys have brought to light previously unrecognized safety problems, although discrepancies have been shown to exist between patient reports and other methods for detecting adverse events. Most respondents attributed adverse events to individual physicians and nurses rather than health systems, underscoring the challenge of conveying blame-free culture and systems approaches to the public. Diagnostic errors were the most common type of error reported. About half of patients who experienced medical errors reported the incident to a clinician, hospital, or official agency. Most patients did not look for safety or quality information in choosing a physician or hospital, and only a third of respondents view patient safety as a serious problem for the state. Importantly, prior to being given an explanation, less than half of respondents understood the term "medical error." These findings emphasize the divide between the high prevalence of safety hazards and the lack of public awareness of patient safety efforts and policy.
Berenson RA, Upadhyay D, Kaye DR. Washington, DC: Urban Institute. Princeton, NJ: Robert Wood Johnson Foundation; 2014.
This comprehensive policy brief emphasizes the importance of addressing diagnostic errors through health policy change. The report explores the role of missed and delayed diagnosis in malpractice claims and preventable harm to patients. The authors note the lack of attention to diagnosis in the seminal To Err is Human report. They outline several strategies to detect and characterize diagnostic errors, including patient and provider surveys, case review, voluntary reporting, claims review, audits, and trigger tools in electronic medical records. To enhance timely and accurate diagnoses, the report advocates for increasing research funding, greater government oversight, instituting formal diagnostic feedback mechanisms, and payment and medical education reform.
Reynard J, Reynolds J, Stevenson P. Oxford, UK: Oxford University Press; 2009. ISBN: 9780199239931.
This book provides an introduction to key patient safety topics and includes a set of 20 case studies to demonstrate opportunities for error prevention.
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.
Kahneman D, Slovic P, Tversky A, eds. Cambridge, England: Cambridge University Press; 1982. ISBN-13: 9780521284141.
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.