Patient generated research priorities to improve diagnostic safety: A systematic prioritization exercise

Trends of diagnostic adverse events in hospital deaths: longitudinal analyses of four retrospective record review studies

OBJECTIVES

To investigate longitudinal trends in the incidence, preventability, and causes of DAEs (diagnostic adverse events) between 2008 and 2019 and compare DAEs to other AE (adverse event) types.

METHODS

This study investigated longitudinal trends of DAEs using combined data from four large Dutch AE record review studies. The original four AE studies included 100-150 randomly selected records of deceased patients from around 20 hospitals in each study, resulting in a total of 10,943 patient records. Nurse reviewers indicated cases with potential AEs using a list of triggers. Subsequently, experienced physician reviewers systematically judged the occurrence of AEs, the clinical process in which these AEs occurred, and the preventability and causes.

RESULTS

The incidences of DAEs, potentially preventable DAEs and potentially preventable DAE-related deaths initially declined between 2008 and 2012 (2.3 vs. 1.2; OR=0.52, 95 % CI: 0.32 to 0.83), after which they stabilized up to 2019. These trends were largely the same for other AE types, although compared to DAEs, the incidence of other AE types increased between 2016 (DAE: 1.0, other AE types: 8.5) and 2019 (DAE: 0.8, other AE types: 13.0; rate ratio=1.88, 95 % CI: 1.12 to 2.13). Furthermore, DAEs were more preventable (p<0.001) and were associated with more potentially preventable deaths (p=0.016) than other AE types. In addition, DAEs had more and different underlying causes than other AE types (p<0.001). The DAE causes remained stable over time, except for patient-related factors, which increased between 2016 and 2019 (29.5 and 58.6 % respectively, OR=3.40, 95 % CI: 1.20 to 9.66).

CONCLUSIONS

After initial improvements of DAE incidences in 2012, no further improvement was observed in Dutch hospitals in the last decade. Similar trends were observed for other AEs. The high rate of preventability of DAEs suggest a high potential for improvement, that should be further investigated.

Common contributing factors of diagnostic error: A retrospective analysis of 109 serious adverse event reports from Dutch hospitals

INTRODUCTION

Although diagnostic errors have gained renewed focus within the patient safety domain, measuring them remains a challenge. They are often measured using methods that lack information on decision-making processes given by involved physicians (eg, record reviews). The current study analyses serious adverse event (SAE) reports from Dutch hospitals to identify common contributing factors of diagnostic errors in hospital medicine. These reports are the results of thorough investigations by highly trained, independent hospital committees into the causes of SAEs. The reports include information from involved healthcare professionals and patients or family obtained through interviews.

METHODS

All 71 Dutch hospitals were invited to participate in this study. Participating hospitals were asked to send four diagnostic SAE reports of their hospital. Researchers applied the Safer Dx Instrument, a Generic Analysis Framework, the Diagnostic Error Evaluation and Research (DEER) taxonomy and the Eindhoven Classification Model (ECM) to analyse reports.

RESULTS

Thirty-one hospitals submitted 109 eligible reports. Diagnostic errors most often occurred in the diagnostic testing, assessment and follow-up phases according to the DEER taxonomy. The ECM showed human errors as the most common contributing factor, especially relating to communication of results, task planning and execution, and knowledge. Combining the most common DEER subcategories and the most common ECM classes showed that clinical reasoning errors resulted from failures in knowledge, and task planning and execution. Follow-up errors and errors with communication of test results resulted from failures in coordination and monitoring, often accompanied by usability issues in electronic health record design and missing protocols.

DISCUSSION

Diagnostic errors occurred in every hospital type, in different specialties and with different care teams. While clinical reasoning errors remain a common problem, often caused by knowledge and skill gaps, other frequent errors in communication of test results and follow-up require different improvement measures (eg, improving technological systems).

Patient and family contributions to improve the diagnostic process through the OurDX electronic health record tool: a mixed method analysis

BACKGROUND

Accurate and timely diagnosis relies on sharing perspectives among team members and avoiding information asymmetries. Patients/Families hold unique diagnostic process (DxP) information, including knowledge of diagnostic safety blindspots-information that patients/families know, but may be invisible to clinicians. To improve information sharing, we co-developed with patients/families an online tool called 'Our Diagnosis (OurDX)'. We aimed to characterise patient/family contributions in OurDX and how they differed between individuals with and without diagnostic concerns.

METHOD

We implemented OurDX in two academic organisations serving patients/families living with chronic conditions in three subspecialty clinics and one primary care clinic. Prior to each visit, patients/families were invited to contribute visit priorities, recent histories and potential diagnostic concerns. Responses were available in the electronic health record and could be incorporated by clinicians into visit notes. We randomly sampled OurDX reports with and without diagnostic concerns for chart review and used inductive and deductive qualitative analysis to assess patient/family contributions.

RESULTS

7075 (39%) OurDX reports were submitted at 18 129 paediatric subspecialty clinic visits and 460 (65%) reports were submitted among 706 eligible adult primary care visits. Qualitative analysis of OurDX reports in the chart review sample (n=450) revealed that participants contributed DxP information across 10 categories, most commonly: clinical symptoms/medical history (82%), tests/referrals (54%) and diagnosis/next steps (51%). Participants with diagnostic concerns were more likely to contribute information on DxP risks including access barriers, recent visits for the same problem, problems with tests/referrals or care coordination and communication breakdowns, some of which may represent diagnostic blindspots.

CONCLUSION

Partnering with patients and families living with chronic conditions through OurDX may help clinicians gain a broader perspective of the DxP, including unique information to coproduce diagnostic safety.

The role of patient organisations in research and development: Evidence from rare diseases

Patient organisations play an increasingly crucial role in the pharmaceutical sector, yet their impact on innovation remains unexplored. We estimate the impact of patient organisations on R&D activity in the context of rare diseases in Europe using a proprietary dataset that maps clinical trials from discovery to phase III across 29 countries, 1893 indications, and 30 years (1990-2019). By applying difference-in-differences and event study methodologies to a panel of 1,646,910 unique R&D observations, we find that country-indication pairs with at least one operating patient organisation have a higher rate of R&D activity compared to those without, with stronger effect in more prevalent rare diseases compared to ultra-rare conditions. We observe a lag in effects from patient organisation introduction, suggesting it takes approximately five years for these organisations to affect R&D activity. Overall, our work suggests that patient organisations play an important role in steering R&D efforts in rare diseases. Further research is needed to better understand mechanisms driving this effect and the potential impact of patient organisations on existing health inequities.

Co-Design with Patients for Improving Patient Safety: Strategies, Barriers and pitfalls

What happens when "frontline" workers are patients and family members performing health-related tasks? As more and more complex healthcare tasks are performed by patients and family members, and more emphasis is placed on patient- and family-centered care, strategies are needed to engage patients and family members in co-design "work systems" and patient-professional collaborative work. Human factors professionals are well-equipped to apply participatory ergonomics to patient and collaborative tasks. However, there are a number of barriers and pitfalls in engaging patients in design. Moving from tokenism to meaningful engagement in research requires patience, constant reflection, and a commitment to codesign. Our panel will explore the continuum of engagement and strategies to move from tokenism to partnership to cocreation in patient safety research, ranging from ambulatory medication safety to diagnosis in the emergency department. Strategies and barriers are presented as a starting point to discuss how to achieve effective work system designs.