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van Sassen CGM, van den Berg PJ, Mamede S, Knol L, Eikens-Jansen MP, van den Broek WW, Bindels PJE, Zwaan L. Identifying and prioritizing educational content from a malpractice claims database for clinical reasoning education in the vocational training of general practitioners. ADVANCES IN HEALTH SCIENCES EDUCATION : THEORY AND PRACTICE 2022:10.1007/s10459-022-10194-8. [PMID: 36529764 DOI: 10.1007/s10459-022-10194-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 11/27/2022] [Indexed: 06/17/2023]
Abstract
Diagnostic reasoning is an important topic in General Practitioners' (GPs) vocational training. Interestingly, research has paid little attention to the content of the cases used in clinical reasoning education. Malpractice claims of diagnostic errors represent cases that impact patients and that reflect potential knowledge gaps and contextual factors. With this study, we aimed to identify and prioritize educational content from a malpractice claims database in order to improve clinical reasoning education in GP training. With input from various experts in clinical reasoning and diagnostic error, we defined five priority criteria that reflect educational relevance. Fifty unique medical conditions from a malpractice claims database were scored on those priority criteria by stakeholders in clinical reasoning education in 2021. Subsequently, we calculated the mean total priority score for each condition. Mean total priority score (min 5-max 25) for all fifty diagnoses was 17,11 with a range from 13,89 to 19,61. We identified and described the fifteen highest scoring diseases (with priority scores ranging from 18,17 to 19,61). The prioritized conditions involved complex common (e.g., cardiovascular diseases, renal insufficiency and cancer), complex rare (e.g., endocarditis, ectopic pregnancy, testicular torsion) and more straightforward common conditions (e.g., tendon rupture/injury, eye infection). The claim cases often demonstrated atypical presentations or complex contextual factors. Including those malpractice cases in GP vocational training could enrich the illness scripts of diseases that are at high risk of errors, which may reduce diagnostic error and related patient harm.
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Affiliation(s)
- Charlotte G M van Sassen
- Department of General Practice, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands.
- Institute of Medical Education Research Rotterdam (iMERR), Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands.
| | - Pieter J van den Berg
- Department of General Practice, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Silvia Mamede
- Institute of Medical Education Research Rotterdam (iMERR), Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Psychology, Education and Child Studies, Erasmus School of Social and Behavioral Sciences, Rotterdam, The Netherlands
| | - Lilian Knol
- VvAA, Orteliuslaan 750, 3528 BB, Utrecht, The Netherlands
| | | | - Walter W van den Broek
- Institute of Medical Education Research Rotterdam (iMERR), Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Patrick J E Bindels
- Department of General Practice, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Laura Zwaan
- Institute of Medical Education Research Rotterdam (iMERR), Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
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2
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Cognitive preceptorship: An emerging nurse practitioner role transition to practice model. J Prof Nurs 2022; 39:194-205. [DOI: 10.1016/j.profnurs.2022.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 01/30/2022] [Accepted: 02/02/2022] [Indexed: 10/19/2022]
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3
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Yousef EA, Sutcliffe KM, McDonald KM, Newman-Toker DE. Crossing Academic Boundaries for Diagnostic Safety: 10 Complex Challenges and Potential Solutions From Clinical Perspectives and High-Reliability Organizing Principles. HUMAN FACTORS 2022; 64:6-20. [PMID: 33657891 DOI: 10.1177/0018720821996187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
OBJECTIVE We apply the high-reliability organization (HRO) paradigm to the diagnostic process, outlining challenges to enacting HRO principles in diagnosis and offering solutions for how diagnostic process stakeholders can overcome these barriers. BACKGROUND Evidence shows that healthcare is starting to organize for higher reliability by employing various principles and practices of HRO. These hold promise for enhancing safer care, but there has been little consideration of the challenges that clinicians and healthcare systems face while enacting HRO principles in the diagnostic process. To effectively deploy the HRO perspective, these barriers must be seriously considered. METHOD We review key principles of the HRO paradigm, the diagnostic errors and harms that potentially can be prevented by its enactment, the challenges that clinicians and healthcare systems face in executing various principles and practices, and possible solutions that clinicians and organizational leaders can take to overcome these challenges and barriers. RESULTS Our analyses reveal multiple challenges including the inherent diagnostic uncertainty; the lack of diagnosis-focused performance feedback; the fact that diagnosis is often a solo, rather than team, activity; the tendency to simplify the diagnostic process; and professional and institutional status hierarchies. But these challenges are not insurmountable-there are strategies and solutions available to overcome them. CONCLUSION The HRO lens offers some important ideas for how the safety of the diagnostic process can be improved. APPLICATION The ideas proposed here can be enacted by both individual clinicians and healthcare leaders; both are necessary for making systematic progress in enhancing diagnostic performance.
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Affiliation(s)
- Elham A Yousef
- 24575 University Hospitals, Cleveland Medical Center. Case Western Reserve University, Ohio, USA
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Kotwal S, Fanai M, Fu W, Wang Z, Bery AK, Omron R, Tevzadze N, Gold D, Garibaldi BT, Wright SM, Newman-Toker DE. Real-world virtual patient simulation to improve diagnostic performance through deliberate practice: a prospective quasi-experimental study. ACTA ACUST UNITED AC 2021; 8:489-496. [PMID: 33675203 DOI: 10.1515/dx-2020-0127] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 02/05/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Diagnostic errors are pervasive in medicine and most often caused by clinical reasoning failures. Clinical presentations characterized by nonspecific symptoms with broad differential diagnoses (e.g., dizziness) are especially prone to such errors. METHODS We hypothesized that novice clinicians could achieve proficiency diagnosing dizziness by training with virtual patients (VPs). This was a prospective, quasi-experimental, pretest-posttest study (2019) at a single academic medical center. Internal medicine interns (intervention group) were compared to second/third year residents (control group). A case library of VPs with dizziness was developed from a clinical trial (AVERT-NCT02483429). The approach (VIPER - Virtual Interactive Practice to build Expertise using Real cases) consisted of brief lectures combined with 9 h of supervised deliberate practice. Residents were provided dizziness-related reading and teaching modules. Both groups completed pretests and posttests. RESULTS For interns (n=22) vs. residents (n=18), pretest median diagnostic accuracy did not differ (33% [IQR 18-46] vs. 31% [IQR 13-50], p=0.61) between groups, while posttest accuracy did (50% [IQR 42-67] vs. 20% [IQR 17-33], p=0.001). Pretest median appropriate imaging did not differ (33% [IQR 17-38] vs. 31% [IQR 13-38], p=0.89) between groups, while posttest appropriateness did (65% [IQR 52-74] vs. 25% [IQR 17-36], p<0.001). CONCLUSIONS Just 9 h of deliberate practice increased diagnostic skills (both accuracy and testing appropriateness) of medicine interns evaluating real-world dizziness 'in silico' more than ∼1.7 years of residency training. Applying condensed educational experiences such as VIPER across a broad range of common presentations could significantly enhance diagnostic education and translate to improved patient care.
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Affiliation(s)
- Susrutha Kotwal
- Department of Medicine, Division of Hospital Medicine, Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Center for Diagnostic Excellence, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mehdi Fanai
- Center for Diagnostic Excellence, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Neurology, Division of Neuro-Visual & Vestibular Disorders, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Wei Fu
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Zheyu Wang
- Center for Diagnostic Excellence, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Anand K Bery
- Department of Medicine, Division of Neurology, The Ottawa Hospital, Ottawa, Canada
| | - Rodney Omron
- Center for Diagnostic Excellence, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nana Tevzadze
- Department of Neurology, Division of Neuro-Visual & Vestibular Disorders, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Daniel Gold
- Department of Neurology, Division of Neuro-Visual & Vestibular Disorders, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Brian T Garibaldi
- Center for Diagnostic Excellence, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Scott M Wright
- Department of Medicine, Division of Hospital Medicine, Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David E Newman-Toker
- Center for Diagnostic Excellence, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Neurology, Division of Neuro-Visual & Vestibular Disorders, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Newman-Toker DE, Schaffer AC, Yu-Moe CW, Nassery N, Saber Tehrani AS, Clemens GD, Wang Z, Zhu Y, Fanai M, Siegal D. Serious misdiagnosis-related harms in malpractice claims: The “Big Three” – vascular events, infections, and cancers. Diagnosis (Berl) 2019; 6:227-240. [DOI: 10.1515/dx-2019-0019] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 04/28/2019] [Indexed: 12/30/2022]
Abstract
Abstract
Background
Diagnostic errors cause substantial preventable harm, but national estimates vary widely from 40,000 to 4 million annually. This cross-sectional analysis of a large medical malpractice claims database was the first phase of a three-phase project to estimate the US burden of serious misdiagnosis-related harms.
Methods
We sought to identify diseases accounting for the majority of serious misdiagnosis-related harms (morbidity/mortality). Diagnostic error cases were identified from Controlled Risk Insurance Company (CRICO)’s Comparative Benchmarking System (CBS) database (2006–2015), representing 28.7% of all US malpractice claims. Diseases were grouped according to the Agency for Healthcare Research and Quality (AHRQ) Clinical Classifications Software (CCS) that aggregates the International Classification of Diseases diagnostic codes into clinically sensible groupings. We analyzed vascular events, infections, and cancers (the “Big Three”), including frequency, severity, and settings. High-severity (serious) harms were defined by scores of 6–9 (serious, permanent disability, or death) on the National Association of Insurance Commissioners (NAIC) Severity of Injury Scale.
Results
From 55,377 closed claims, we analyzed 11,592 diagnostic error cases [median age 49, interquartile range (IQR) 36–60; 51.7% female]. These included 7379 with high-severity harms (53.0% death). The Big Three diseases accounted for 74.1% of high-severity cases (vascular events 22.8%, infections 13.5%, and cancers 37.8%). In aggregate, the top five from each category (n = 15 diseases) accounted for 47.1% of high-severity cases. The most frequent disease in each category, respectively, was stroke, sepsis, and lung cancer. Causes were disproportionately clinical judgment factors (85.7%) across categories (range 82.0–88.8%).
Conclusions
The Big Three diseases account for about three-fourths of serious misdiagnosis-related harms. Initial efforts to improve diagnosis should focus on vascular events, infections, and cancers.
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Omron R, Kotwal S, Garibaldi BT, Newman‐Toker DE. The Diagnostic Performance Feedback "Calibration Gap": Why Clinical Experience Alone Is Not Enough to Prevent Serious Diagnostic Errors. AEM EDUCATION AND TRAINING 2018; 2:339-342. [PMID: 30386846 PMCID: PMC6194049 DOI: 10.1002/aet2.10119] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 07/28/2018] [Indexed: 06/08/2023]
Affiliation(s)
- Rodney Omron
- Johns Hopkins University School of MedicineBaltimoreMD
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8
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Hoyt KS, Ramirez E, Topp R, Nichols S, Agan D. Comparing nurse practitioners/physician assistants and physicians in diagnosing adult abdominal pain in the emergency department. J Am Assoc Nurse Pract 2018; 30:655-661. [PMID: 30095670 DOI: 10.1097/jxx.0000000000000083] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND PURPOSE This retrospective study compared nurse practitioners and physician assistants (NPs/PAs) with physicians on their assignment of Emergency Severity Index level 3 (ESI level 3) acute abdominal pain (AAP) in the emergency department (ED). METHODS Data obtained from a large ED group staffing four hospitals yielded 12,440 de-identified, adult patients diagnosed on ED admission with AAP ESI level 3 for descriptive analysis with logistic regression. CONCLUSIONS Results revealed that the comparison of ESI level 3 AAP diagnoses was consistent between admission and discharge 95.3% for physicians, 92.9% for NPs/PAs, and 97.1% for NP/PA and physician collaboration (χ = 46.01, p < .001). Logistic regression suggested that NP/PA had significantly reduced odds (31%) of consistent admitting/discharge diagnoses, whereas collaboration of NP/PA with physicians had significantly increased odds of consistent diagnosis (41%) compared with physicians alone. Two hospitals with similar distributions of NPs/PAs and physicians exhibited greater odds of consistent diagnoses over hospitals with disproportionate distributions; a secondary finding worth exploring. Consistent AAP ESI level 3 diagnoses by outcomes were admissions (>99%), discharges (94%), and left against medical advice/transferred (98%; χ = 102.94, p < .001). IMPLICATIONS FOR PRACTICE The highest percentage of consistent AAP ESI level 3 diagnoses between ED admission and discharge was when NPs/PAs and physicians collaborated.
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Affiliation(s)
- Karen Sue Hoyt
- Hahn School of Nursing and Health Science, Beyster Institute of Nursing Research, University of San Diego, San Diego, California
| | - Elda Ramirez
- University of Texas Health Science Center Houston, Houston, Texas
| | - Robert Topp
- Hahn School of Nursing and Health Science, Beyster Institute of Nursing Research, University of San Diego, San Diego, California
| | - Stephen Nichols
- Emergency Medicine & Hospital Medicine, Schumacher Group, Lafayette, Louisiana
| | - Donna Agan
- Hahn School of Nursing and Health Science, Beyster Institute of Nursing Research, University of San Diego, San Diego, California
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Rencic J, Trowbridge RL, Fagan M, Szauter K, Durning S. Clinical Reasoning Education at US Medical Schools: Results from a National Survey of Internal Medicine Clerkship Directors. J Gen Intern Med 2017; 32:1242-1246. [PMID: 28840454 PMCID: PMC5653563 DOI: 10.1007/s11606-017-4159-y] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 03/30/2017] [Accepted: 08/07/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Recent reports, including the Institute of Medicine's Improving Diagnosis in Health Care, highlight the pervasiveness and underappreciated harm of diagnostic error, and recommend enhancing health care professional education in diagnostic reasoning. However, little is known about clinical reasoning curricula at US medical schools. OBJECTIVE To describe clinical reasoning curricula at US medical schools and to determine the attitudes of internal medicine clerkship directors toward teaching of clinical reasoning. DESIGN Cross-sectional multicenter study. PARTICIPANTS US institutional members of the Clerkship Directors in Internal Medicine (CDIM). MAIN MEASURES Examined responses to a survey that was emailed in May 2015 to CDIM institutional representatives, who reported on their medical school's clinical reasoning curriculum. KEY RESULTS The response rate was 74% (91/123). Most respondents reported that a structured curriculum in clinical reasoning should be taught in all phases of medical education, including the preclinical years (64/85; 75%), clinical clerkships (76/87; 87%), and the fourth year (75/88; 85%), and that more curricular time should be devoted to the topic. Respondents indicated that most students enter the clerkship with only poor (25/85; 29%) to fair (47/85; 55%) knowledge of key clinical reasoning concepts. Most institutions (52/91; 57%) surveyed lacked sessions dedicated to these topics. Lack of curricular time (59/67, 88%) and faculty expertise in teaching these concepts (53/76, 69%) were identified as barriers. CONCLUSIONS Internal medicine clerkship directors believe that clinical reasoning should be taught throughout the 4 years of medical school, with the greatest emphasis in the clinical years. However, only a minority reported having teaching sessions devoted to clinical reasoning, citing a lack of curricular time and faculty expertise as the largest barriers. Our findings suggest that additional institutional and national resources should be dedicated to developing clinical reasoning curricula to improve diagnostic accuracy and reduce diagnostic error.
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Affiliation(s)
| | | | - Mark Fagan
- Rhode Island Hospital, Providence, RI, USA
| | - Karen Szauter
- University of Texas Medical Branch, Galveston, TX, USA
| | - Steven Durning
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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Teaching diagnostic reasoning: using simulation and mixed practice to build competence. CAN J EMERG MED 2017; 20:142-145. [PMID: 28743323 DOI: 10.1017/cem.2017.357] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The acquisition of competence in diagnostic reasoning is essential for medical trainees. Exposure to a variety of patient presentations helps develop the skills of diagnostic reasoning, but reliance on ad hoc clinical encounters is inefficient and does not guarantee timely exposure for all trainees. We present a novel teaching series led by emergency physicians that builds upon the existing medical education literature to teach diagnostic reasoning to preclinical (2nd year) medical students. The series used emergency department simulations involving patient actors and simulated vital signs to provide students with exposure to three acute care presentations: chest pain, abdominal pain, and headache. Emergency physicians coached and provided immediate feedback to the students as they actively worked through diagnostic reasoning. The participating medical students reported benefit from these sessions immediately following the sessions and in an 18-month follow-up survey where the students could consider the impact of the sessions on their clinical clerkship. Students felt that the sessions had assisted them in recognizing the key features of relevant diagnoses during clerkship as well as providing a helpful adjunct to their in-class learning.
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11
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Nurse Practitioners’ Versus Physicians’ Diagnostic Reasoning Style and Use of Maxims: A Comparative Study. J Nurse Pract 2016. [DOI: 10.1016/j.nurpra.2016.02.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Carpenter CR, Raja AS, Brown MD. Overtesting and the Downstream Consequences of Overtreatment: Implications of "Preventing Overdiagnosis" for Emergency Medicine. Acad Emerg Med 2015; 22:1484-92. [PMID: 26568269 DOI: 10.1111/acem.12820] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Revised: 07/03/2015] [Accepted: 07/07/2015] [Indexed: 12/15/2022]
Abstract
Overtesting, the downstream consequences of overdiagnosis, and overtreatment of some patients are topics of growing debate within emergency medicine (EM). The "Preventing Overdiagnosis" conference, hosted by The Dartmouth Institute for Health Policy and Clinical Practice, with sponsorship from consumer organizations, medical journals, and academic institutions, is evidence of an expanding interest in this topic. However, EM represents a compellingly unique environment, with increased decision density tied to high stakes for patients and providers with missed or delayed diagnoses in a professional atmosphere that does not tolerate mistakes. This article reviews the relevance of this reductionist paradigm to EM, provides a first-hand synopsis of the first "Preventing Overdiagnosis" conference, and assesses barriers to moving the concept of less test ordering to reality.
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Affiliation(s)
- Christopher R. Carpenter
- Division of Emergency Medicine; Washington University in St. Louis School of Medicine; St. Louis MO
| | - Ali S. Raja
- Department of Emergency Medicine; Brigham & Women's Hospital; Boston MA
| | - Michael D. Brown
- Emergency Medicine; Michigan State University College of Medicine; Grand Rapids MI
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Medford-Davis L, Park E, Shlamovitz G, Suliburk J, Meyer AND, Singh H. Diagnostic errors related to acute abdominal pain in the emergency department. Emerg Med J 2015; 33:253-9. [PMID: 26531859 DOI: 10.1136/emermed-2015-204754] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Accepted: 09/05/2015] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Diagnostic errors in the emergency department (ED) are harmful and costly. We reviewed a selected high-risk cohort of patients presenting to the ED with abdominal pain to evaluate for possible diagnostic errors and associated process breakdowns. DESIGN We conducted a retrospective chart review of ED patients >18 years at an urban academic hospital. A computerised 'trigger' algorithm identified patients possibly at high risk for diagnostic errors to facilitate selective record reviews. The trigger determined patients to be at high risk because they: (1) presented to the ED with abdominal pain, and were discharged home and (2) had a return ED visit within 10 days that led to a hospitalisation. Diagnostic errors were defined as missed opportunities to make a correct or timely diagnosis based on the evidence available during the first ED visit, regardless of patient harm, and included errors that involved both ED and non-ED providers. Errors were determined by two independent record reviewers followed by team consensus in cases of disagreement. RESULTS Diagnostic errors occurred in 35 of 100 high-risk cases. Over two-thirds had breakdowns involving the patient-provider encounter (most commonly history-taking or ordering additional tests) and/or follow-up and tracking of diagnostic information (most commonly follow-up of abnormal test results). The most frequently missed diagnoses were gallbladder pathology (n=10) and urinary infections (n=5). CONCLUSIONS Diagnostic process breakdowns in ED patients with abdominal pain most commonly involved history-taking, ordering insufficient tests in the patient-provider encounter and problems with follow-up of abnormal test results.
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Affiliation(s)
- Laura Medford-Davis
- Department of Emergency Medicine, Robert Wood Johnson Foundation Clinical Scholars, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Elizabeth Park
- Section of Emergency Medicine, Baylor College of Medicine and Harris Health System, Ben Taub General Hospital Emergency Center, Houston, Texas, USA
| | - Gil Shlamovitz
- Department of Emergency Medicine, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - James Suliburk
- Michael E DeBakey Department of Surgery, Baylor College of Medicine and Harris Health System, Houston, Texas, USA
| | - Ashley N D Meyer
- Houston Veterans Affairs Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas, USA
| | - Hardeep Singh
- Houston Veterans Affairs Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas, USA
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