Diagnostic errors: moving beyond 'no respect' and getting ready for prime time

Healthcare Quality from the Perspective of Patients in Gulf Cooperation Council Countries: A Systematic Literature Review

With the increased focus on patient-centered care, consensus on healthcare outcomes of importance to patients becomes crucial. Based on a systematic review of the literature, this study confirms the perspectives of patients on healthcare quality in GCC countries. Online databases were searched for relevant peer-reviewed articles published from 2012 to 2023. Twenty-two articles retrieved from the search were qualitatively analyzed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Most articles (90%) reported studies conducted in Saudi Arabia. Patients in GCC countries face common problems in the care delivery process, which contribute to negative perceptions of quality. These problems include diagnostic and medication errors, provider-patient communication problems, missed appointments with physicians, problems in emergency care access due to geographical distance and transportation barriers, long waiting times, and physical environments. Notably, healthcare quality is perceived to be an outcome of multiple factors dependent on the location and category of healthcare service providers; for instance, disparities in perceptions of quality were observed between patients attending Primary Health Care (PHC) centers in rural and urban areas. Issues such as lack of equitable healthcare delivery and deficiencies in Emergency Medical Services (EMS) effectiveness were disparately recognized as quality concerns by different patient populations. The findings provide insights into healthcare quality and area of weakness needing strategies and policies to ensure patient-centered, safe, equitable, timely, and effective healthcare. Healthcare providers and policymakers in GCC countries can use the results to plan, assess, and improve care delivery. Trial registration: PROSPERO ID: CRD42022326842.

Characterising the types of paediatric adverse events detected by the global trigger tool – CareTrack Kids

Introduction

A common method of learning about adverse events (AEs) is by reviewing medical records using the global trigger tool (GTT). However, these studies generally report rates of harm. The aim of this study is to characterise paediatric AEs detected by the GTT using descriptive and qualitative approaches.

Methods

Medical records of children aged 0–15 were reviewed for presence of harm using the GTT. Records from 2012–2013 were sampled from hospital inpatients, emergency departments, general practice and specialist paediatric practices in three Australian states. Nurses undertook a review of each record and if an AE was suspected a doctor performed a verification review of a summary created by the nurse. A qualitative content analysis was undertaken on the summary of verified AEs.

Results

A total of 232 AEs were detected from 6,689 records reviewed. Over four-fifths of the AEs (193/232, 83%) resulted in minor harm to the patient. Nearly half (112/232, 48%) related to medication/intravenous (IV) fluids. Of these, 83% (93/112) were adverse drug reactions. Problems with medical devices/equipment were the next most frequent with nearly two-thirds (32/51, 63%) of these related to intravenous devices. Problems associated with clinical processes/procedures comprise one in six AEs (38/232, 16%), of which diagnostic problems (12/38, 32%) and procedural complications (11/38, 29%) were the most frequent.

Conclusion

Adverse drug reactions and issues with IVs are frequently identified AEs reflecting their common use in paediatrics. The qualitative approach taken in this study allowed AE types to be characterised, which is a prerequisite for developing and prioritising improvements in practice.

Operational measurement of diagnostic safety: state of the science

Reducing the incidence of diagnostic errors is increasingly a priority for government, professional, and philanthropic organizations. Several obstacles to measurement of diagnostic safety have hampered progress toward this goal. Although a coordinated national strategy to measure diagnostic safety remains an aspirational goal, recent research has yielded practical guidance for healthcare organizations to start using measurement to enhance diagnostic safety. This paper, concurrently published as an Issue Brief by the Agency for Healthcare Research and Quality, issues a "call to action" for healthcare organizations to begin measurement efforts using data sources currently available to them. Our aims are to outline the state of the science and provide practical recommendations for organizations to start identifying and learning from diagnostic errors. Whether by strategically leveraging current resources or building additional capacity for data gathering, nearly all organizations can begin their journeys to measure and reduce preventable diagnostic harm.

Measures to Improve Diagnostic Safety in Clinical Practice

Timely and accurate diagnosis is foundational to good clinical practice and an essential first step to achieving optimal patient outcomes. However, a recent Institute of Medicine report concluded that most of us will experience at least one diagnostic error in our lifetime. The report argues for efforts to improve the reliability of the diagnostic process through better measurement of diagnostic performance. The diagnostic process is a dynamic team-based activity that involves uncertainty, plays out over time, and requires effective communication and collaboration among multiple clinicians, diagnostic services, and the patient. Thus, it poses special challenges for measurement. In this paper, we discuss how the need to develop measures to improve diagnostic performance could move forward at a time when the scientific foundation needed to inform measurement is still evolving. We highlight challenges and opportunities for developing potential measures of "diagnostic safety" related to clinical diagnostic errors and associated preventable diagnostic harm. In doing so, we propose a starter set of measurement concepts for initial consideration that seem reasonably related to diagnostic safety and call for these to be studied and further refined. This would enable safe diagnosis to become an organizational priority and facilitate quality improvement. Health-care systems should consider measurement and evaluation of diagnostic performance as essential to timely and accurate diagnosis and to the reduction of preventable diagnostic harm.

Strategies to reduce diagnostic errors: a systematic review

Background

To evaluate the effectiveness of audit and communication strategies to reduce diagnostic errors made by clinicians.

Methods

MEDLINE complete, CINHAL complete, EMBASE, PSNet and Google Advanced. Electronic and manual search of articles on audit systems and communication strategies or interventions, searched for papers published between January 1990 and April 2017. We included studies with interventions implemented by clinicians in a clinical environment with real patients.

Results

A total of 2431 articles were screened of which 26 studies met inclusion criteria. Data extraction was conducted by two groups, each group comprising two independent reviewers. Articles were classified by communication (6) or audit strategies (20) to reduce diagnostic error in clinical settings. The most common interventions were delivered as technology-based systems n = 16 (62%) and within an acute care setting n = 15 (57%). Nine studies reported randomised controlled trials. Three RCT studies on communication interventions and 3 RCTs on audit strategies found the interventions to be effective in reducing diagnostic errors.

Conclusion

Despite numerous studies on interventions targeting diagnostic errors, our analyses revealed limited evidence on interventions being practically used in clinical settings and a bias of studies originating from the US (n = 19, 73% of included studies). There is some evidence that trigger algorithms, including computer based and alert systems, may reduce delayed diagnosis and improve diagnostic accuracy. In trauma settings, strategies such as additional patient review (e.g. trauma teams) reduced missed diagnosis and in radiology departments review strategies such as team meetings and error documentation may reduce diagnostic error rates over time.

Trial registration

The systematic review was registered in the PROSPERO database under registration number CRD42017067056.

Electronic supplementary material

The online version of this article (10.1186/s12911-019-0901-1) contains supplementary material, which is available to authorized users.

Risk of death within 7 days of discharge from emergency departments with different organizational models

OBJECTIVE

The aim of this study is to investigate the association between emergency department (ED) organizational models and the risk of death within 7 days of ED discharge.

PATIENTS AND METHODS

We included Danish ED discharges between 1 January 2011 and 24 December 2014 that led to death within 7 days of discharge. The inclusion criterion was age older than 18 years. The exclusion criterion was further in-hospital admission. First model (Virtual): other departments employ interns who perform ED tasks. They are responsible for ED patient care and prioritize their task order between their own department and the ED. Second model (Hybrid): the ED/other departments perform tasks; interns/consultants are employed by the ED/other departments. The ED/other departments have patient care responsibility. Third model (Independent): the ED performs all tasks; employs interns/consultants; and have patient care responsibility. Sex, age, Charlson Comorbidity Index score, and primary diagnosis were used to describe patient characteristics. We calculated the risk of death within 7 days of discharge using multiple logistic regression analysis.

RESULTS

In 805 out of 201 299 discharges included in the study, the patient died within 7 days. Compared with the Virtual model, the odds ratio for death within 7 days of discharge was 0.72 (95% confidence interval: 0.59-0.92) for the Independent model and 0.75 (95% confidence interval: 0.61-0.92) for the Hybrid+Virtual model. Increased risk was associated with male sex, older age, and a medium or a high Charlson Comorbidity Index score.

CONCLUSION

Compared with discharges from a Virtual model, the risk of death within 7 days of discharge was lower if the ED had an Independent or a Hybrid+Virtual model.

Patient involvement in diagnosing cancer in primary care: a systematic review of current interventions

BACKGROUND

Patients can play a role in achieving an earlier diagnosis of cancer by monitoring and re-appraising symptoms after initially presenting to primary care. It is not clear what interventions exist, or what the components of an intervention to engage patients at this diagnostic stage are.

AIM

The review had two aims: 1) to identify interventions that involve patients, and 2) to establish key components for engaging patients in the diagnosis of cancer in primary care at the post-presentation stage.

DESIGN AND SETTING

Empirical studies and non-empirical articles were identified searching Ovid MEDLINE, PsycINFO, and Embase databases, relevant journals, and available key author publication lists.

METHOD

Abstracts and titles were screened against inclusion and exclusion criteria. Qualitative synthesis of empirical research and current opinion from across all articles was used to select, organise, and interpret findings.

RESULTS

No interventions were found. Sixteen articles provided suggestions for potential interventions and components important at the post-presentation stage. Factors contributing to patients not always being engaged in assisting with diagnosis, strategies to foster patient involvement, and moderators and benefits to patients and health services (proximal and distal outcomes) were captured in a logic model.

CONCLUSION

There is an absence of interventions involving patients during the post-presentation stage of the diagnostic process. Limited literature was drawn upon to identify potential barriers and facilitators for engaging patients at this diagnostic stage, and to establish possible mechanisms of change and measurable outcomes. Findings can direct future research and the development of interventions.

Stroke Chameleons and Stroke Mimics in the Emergency Department

PURPOSE OF REVIEW

We discuss the frequency of stroke misdiagnosis in the emergency department (ED), identify common diagnostic pitfalls, describe strategies to reduce diagnostic error, and detail ongoing research.

RECENT FINDINGS

The National Academy of Medicine has re-defined and highlighted the importance of diagnostic errors for patient safety. Recent rates of stroke under-diagnosis (false-negative cases, "stroke chameleons") range from 2-26% and 30-43% for stroke over-diagnosis (false-positive cases, "stroke mimics"). Failure to diagnosis stroke can preclude time-sensitive treatments and has been associated with poor outcomes. Strategies have been developed to improve detection of posterior circulation stroke syndromes, but ongoing work is needed to reduce under-diagnosis in other atypical stroke presentations. The published rates of harm associated with stroke over-diagnosis, particularly thrombolysis of stroke mimics, remain low. Additional strategies to improve the accuracy of stroke diagnosis should focus on rapid clinical reasoning in the time-sensitive setting of acute ischemic stroke and identifying imperfections in the healthcare system which may contribute to diagnostic error.

The global burden of diagnostic errors in primary care

Diagnosis is one of the most important tasks performed by primary care physicians. The World Health Organization (WHO) recently prioritized patient safety areas in primary care, and included diagnostic errors as a high-priority problem. In addition, a recent report from the Institute of Medicine in the USA, 'Improving Diagnosis in Health Care', concluded that most people will likely experience a diagnostic error in their lifetime. In this narrative review, we discuss the global significance, burden and contributory factors related to diagnostic errors in primary care. We synthesize available literature to discuss the types of presenting symptoms and conditions most commonly affected. We then summarize interventions based on available data and suggest next steps to reduce the global burden of diagnostic errors. Research suggests that we are unlikely to find a 'magic bullet' and confirms the need for a multifaceted approach to understand and address the many systems and cognitive issues involved in diagnostic error. Because errors involve many common conditions and are prevalent across all countries, the WHO's leadership at a global level will be instrumental to address the problem. Based on our review, we recommend that the WHO consider bringing together primary care leaders, practicing frontline clinicians, safety experts, policymakers, the health IT community, medical education and accreditation organizations, researchers from multiple disciplines, patient advocates, and funding bodies among others, to address the many common challenges and opportunities to reduce diagnostic error. This could lead to prioritization of practice changes needed to improve primary care as well as setting research priorities for intervention development to reduce diagnostic error.

Finding Diagnostic Errors in Children Admitted to the PICU

OBJECTIVES

To determine whether the Safer Dx Instrument, a structured tool for finding diagnostic errors in primary care, can be used to reliably detect diagnostic errors in patients admitted to a PICU.

DESIGN AND SETTING

The Safer Dx Instrument consists of 11 questions to evaluate the diagnostic process and a final question to determine if diagnostic error occurred. We used the instrument to analyze four "high-risk" patient cohorts admitted to the PICU between June 2013 and December 2013.

PATIENTS

High-risk cohorts were defined as cohort 1: patients who were autopsied; cohort 2: patients seen as outpatients within 2 weeks prior to PICU admission; cohort 3: patients transferred to PICU unexpectedly from an acute care floor after a rapid response and requiring vasoactive medications and/or endotracheal intubation due to decompensation within 24 hours; and cohort 4: patients transferred to PICU unexpectedly from an acute care floor after a rapid response without subsequent decompensation in 24 hours.

INTERVENTIONS

Two clinicians used the instrument to independently review records in each cohort for diagnostic errors, defined as missed opportunities to make a correct or timely diagnosis. Errors were confirmed by senior expert clinicians.

MEASUREMENTS AND MAIN RESULTS

Diagnostic errors were present in 26 of 214 high-risk patient records (12.1%; 95% CI, 8.2-17.5%) with the following frequency distribution: cohort 1: two of 16 (12.5%); cohort 2: one of 41 (2.4%); cohort 3: 13 of 44 (29.5%); and cohort 4: 10 of 113 (8.8%). Overall initial reviewer agreement was 93.6% (κ, 0.72). Infections and neurologic conditions were the most commonly missed diagnoses across all high-risk cohorts (16/26).

CONCLUSIONS

The Safer Dx Instrument has high reliability and validity for diagnostic error detection when used in high-risk pediatric care settings. With further validation in additional clinical settings, it could be useful to enhance learning and feedback about diagnostic safety in children.

Early death after discharge from emergency departments: analysis of national US insurance claims data

OBJECTIVE

 To measure incidence of early death after discharge from emergency departments, and explore potential sources of variation in risk by measurable aspects of hospitals and patients.

DESIGN

 Retrospective cohort study.

SETTING

 Claims data from the US Medicare program, covering visits to an emergency department, 2007-12.

PARTICIPANTS

 Nationally representative 20% sample of Medicare fee for service beneficiaries. As the focus was on generally healthy people living in the community, patients in nursing facilities, aged ≥90, receiving palliative or hospice care, or with a diagnosis of a life limiting illnesses, either during emergency department visits (for example, myocardial infarction) or in the year before (for example, malignancy) were excluded.

MAIN OUTCOME MEASURE

 Death within seven days after discharge from the emergency department, excluding patients transferred or admitted as inpatients.

RESULTS

 Among discharged patients, 0.12% (12 375/10 093 678, in the 20% sample over 2007-12) died within seven days, or 10 093 per year nationally. Mean age at death was 69. Leading causes of death on death certificates were atherosclerotic heart disease (13.6%), myocardial infarction (10.3%), and chronic obstructive pulmonary disease (9.6%). Some 2.3% died of narcotic overdose, largely after visits for musculoskeletal problems. Hospitals in the lowest fifth of rates of inpatient admission from the emergency department had the highest rates of early death (0.27%)-3.4 times higher than hospitals in the highest fifth (0.08%)-despite the fact that hospitals with low admission rates served healthier populations, as measured by overall seven day mortality among all comers to the emergency department. Small increases in admission rate were linked to large decreases in risk. In multivariate analysis, emergency departments that saw higher volumes of patients (odds ratio 0.84, 95% confidence interval 0.81 to 0.86) and those with higher charges for visits (0.75, 0.74 to 0.77) had significantly fewer deaths. Certain diagnoses were more common among early deaths compared with other emergency department visits: altered mental status (risk ratio 4.4, 95% confidence interval 3.8 to 5.1), dyspnea (3.1, 2.9 to 3.4), and malaise/fatigue (3.0, 2.9 to 3.7).

CONCLUSIONS

 Every year, a substantial number of Medicare beneficiaries die soon after discharge from emergency departments, despite no diagnosis of a life limiting illnesses recorded in their claims. Further research is needed to explore whether these deaths were preventable.

Accuracy of the Safer Dx Instrument to Identify Diagnostic Errors in Primary Care

IMPORTANCE

Diagnostic errors are common and harmful, but difficult to define and measure. Measurement of diagnostic errors often depends on retrospective medical record reviews, frequently resulting in reviewer disagreement.

OBJECTIVES

We aimed to test the accuracy of an instrument to help detect presence or absence of diagnostic error through record reviews.

DESIGN

We gathered questions from several previously used instruments for diagnostic error measurement, then developed and refined our instrument. We tested the accuracy of the instrument against a sample of patient records (n = 389), with and without previously identified diagnostic errors (n = 129 and n = 260, respectively).

RESULTS

The final version of our instrument (titled Safer Dx Instrument) consisted of 11 questions assessing diagnostic processes in the patient-provider encounter and a main outcome question to determine diagnostic error. In comparison with the previous sample, the instrument yielded an overall accuracy of 84 %, sensitivity of 71 %, specificity of 90 %, negative predictive value of 86 %, and positive predictive value of 78 %. All 11 items correlated significantly with the instrument's error outcome question (all p values ≤ 0.01). Using factor analysis, the 11 questions clustered into two domains with high internal consistency (initial diagnostic assessment, and performance and interpretation of diagnostic tests) and a patient factor domain with low internal consistency (Cronbach's alpha coefficients 0.93, 0.92, and 0.38, respectively).

CONCLUSIONS

The Safer Dx Instrument helps quantify the likelihood of diagnostic error in primary care visits, achieving a high degree of accuracy for measuring their presence or absence. This instrument could be useful to identify high-risk cases for further study and quality improvement.

Next steps for electronic health records to improve the diagnostic process

Electronic health record (EHR) usage is accelerating while preventable diagnostic error persists. EHRs may even contribute to diagnostic error through several pathways including poor usability and an over reliance on electronic chart based communication. The changing context of healthcare delivery offers potential financial incentives for organizations to leverage EHRs to reduce diagnostic error. The lack of standard quality metrics for reporting rates of diagnostic error, a lack of diagnostic feedback systems for physicians and organizations, and a lack of compelling evidence for specific interventions underscore the need for further research in preventing diagnostic error. Many potential strategies exist for EHRs to reduce the likelihood of diagnostic error. Practical next steps for leveraging EHR systems to assist in the diagnostic process are suggested. These include patient engagement strategies, closed loop result tracking, targeted next step reminder systems, and expansion of a list of actionable patient states based on diagnosis triggers.

The challenges in defining and measuring diagnostic error

Diagnostic errors have emerged as a serious patient safety problem but they are hard to detect and complex to define. At the research summit of the 2013 Diagnostic Error in Medicine 6th International Conference, we convened a multidisciplinary expert panel to discuss challenges in defining and measuring diagnostic errors in real-world settings. In this paper, we synthesize these discussions and outline key research challenges in operationalizing the definition and measurement of diagnostic error. Some of these challenges include 1) difficulties in determining error when the disease or diagnosis is evolving over time and in different care settings, 2) accounting for a balance between underdiagnosis and overaggressive diagnostic pursuits, and 3) determining disease diagnosis likelihood and severity in hindsight. We also build on these discussions to describe how some of these challenges can be addressed while conducting research on measuring diagnostic error.

Diagnostic error: untapped potential for improving patient safety?

How many diagnostic errors occur? How often do errors cause harm, and how serious is that harm? Do we understand the major causes of diagnostic errors? Really, we don't know how to answer these questions! This article seeks to define a challenge facing all healthcare risk managers, whose usual methods of identifying and analyzing errors have not, and cannot, supply this missing information. What should risk managers do about diagnostic error? Our medical literature acknowledges the existence of a problem, but offers few practical solutions. This article will review some promising theories from the literature regarding how to identify and remediate diagnostic errors, and identify some tools and resources available to risk managers.