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Ladell MM, Yale S, Bordini BJ, Scanlon MC, Jacobson N, Papautsky EL. Why a sociotechnical framework is necessary to address diagnostic error. BMJ Qual Saf 2024:bmjqs-2024-017231. [PMID: 39097407 DOI: 10.1136/bmjqs-2024-017231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 07/18/2024] [Indexed: 08/05/2024]
Affiliation(s)
- Meagan M Ladell
- Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Sarah Yale
- Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Brett J Bordini
- Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | | | - Nancy Jacobson
- Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Elizabeth Lerner Papautsky
- Department of Biomedical & Health Information Sciences, University of Illinois Chicago, Chicago, Illinois, USA
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2
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Brady PW, Ruddy RM, Ehrhardt J, Corathers SD, Kirkendall ES, Walsh KE. Assessing the Revised Safer Dx Instrument ® in the understanding of ambulatory system design changes for type 1 diabetes and autism spectrum disorder in pediatrics. Diagnosis (Berl) 2024; 11:266-272. [PMID: 38517065 PMCID: PMC11306753 DOI: 10.1515/dx-2023-0166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 02/27/2024] [Indexed: 03/23/2024]
Abstract
OBJECTIVES We sought within an ambulatory safety study to understand if the Revised Safer Dx instrument may be helpful in identification of diagnostic missed opportunities in care of children with type 1 diabetes (T1D) and autism spectrum disorder (ASD). METHODS We reviewed two months of emergency department (ED) encounters for all patients at our tertiary care site with T1D and a sample of such encounters for patients with ASD over a 15-month period, and their pre-visit communication methods to better understand opportunities to improve diagnosis. We applied the Revised Safer Dx instrument to each diagnostic journey. We chose potentially preventable ED visits for hyperglycemia, diabetic ketoacidosis, and behavioral crises, and reviewed electronic health record data over the prior three months related to the illness that resulted in the ED visit. RESULTS We identified 63 T1D and 27 ASD ED visits. Using the Revised Safer Dx instrument, we did not identify any potentially missed opportunities to improve diagnosis in T1D. We found two potential missed opportunities (Safer Dx overall score of 5) in ASD, related to potential for ambulatory medical management to be improved. Over this period, 40 % of T1D and 52 % of ASD patients used communication prior to the ED visit. CONCLUSIONS Using the Revised Safer Dx instrument, we uncommonly identified missed opportunities to improve diagnosis in patients who presented to the ED with potentially preventable complications of their chronic diseases. Future researchers should consider prospectively collected data as well as development or adaptation of tools like the Safer Dx.
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Affiliation(s)
- Patrick W. Brady
- Division of Hospital Medicine, Cincinnati Children’s Hospital, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital, Cincinnati, OH, USA
| | - Richard M. Ruddy
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Division of Emergency Medicine, Cincinnati Children’s Hospital, Cincinnati, OH, USA
| | - Jennifer Ehrhardt
- Division of Development and Behavioral Pediatrics, Cincinnati Children’s Hospital, Cincinnati, OH, USA
| | - Sarah D. Corathers
- Division of Hospital Medicine, Cincinnati Children’s Hospital, Cincinnati, OH, USA
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital, Cincinnati, OH, USA
- Division of Endocrinology, Cincinnati Children’s Hospital, Cincinnati, OH, USA
| | - Eric S. Kirkendall
- Department of Pediatrics, Wake Forest School of Medicine, Winston-Salem, NC, USA
- Center for Healthcare Innovation, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Kathleen E. Walsh
- Department of General Pediatrics, Harvard Medical School, Boston, MA, USA
- Division of General Pediatrics, Boston Children’s Hospital,, Boston, MA, USA
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3
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Kapadia P, Zimolzak AJ, Upadhyay DK, Korukonda S, Murugaesh Rekha R, Mushtaq U, Mir U, Murphy DR, Offner A, Abel GA, Lyratzopoulos G, Mounce LT, Singh H. Development and Implementation of a Digital Quality Measure of Emergency Cancer Diagnosis. J Clin Oncol 2024; 42:2506-2515. [PMID: 38718321 PMCID: PMC11268555 DOI: 10.1200/jco.23.01523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 02/08/2024] [Accepted: 02/16/2024] [Indexed: 07/19/2024] Open
Abstract
PURPOSE Missed and delayed cancer diagnoses are common, harmful, and often preventable. Automated measures of quality of cancer diagnosis are lacking but could identify gaps and guide interventions. We developed and implemented a digital quality measure (dQM) of cancer emergency presentation (EP) using electronic health record databases of two health systems and characterized the measure's association with missed opportunities for diagnosis (MODs) and mortality. METHODS On the basis of literature and expert input, we defined EP as a new cancer diagnosis within 30 days after emergency department or inpatient visit. We identified EPs for lung cancer and colorectal cancer (CRC) in the Department of Veterans Affairs (VA) and Geisinger from 2016 to 2020. We validated measure accuracy and identified preceding MODs through standardized chart review of 100 records per cancer per health system. Using VA's longitudinal encounter and mortality data, we applied logistic regression to assess EP's association with 1-year mortality, adjusting for cancer stage and demographics. RESULTS Among 38,565 and 2,914 patients with lung cancer and 14,674 and 1,649 patients with CRCs at VA and Geisinger, respectively, our dQM identified EPs in 20.9% and 9.4% of lung cancers, and 22.4% and 7.5% of CRCs. Chart reviews revealed high positive predictive values for EPs across sites and cancer types (72%-90%), and a substantial percent represented MODs (48.8%-84.9%). EP was associated with significantly higher odds of 1-year mortality for lung cancer and CRC (adjusted odds ratio, 1.78 and 1.83, respectively, 95% CI, 1.63 to 1.86 and 1.61 to 2.07). CONCLUSION A dQM for cancer EP was strongly associated with both mortality and MODs. The findings suggest a promising automated approach to measuring quality of cancer diagnosis in US health systems.
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Affiliation(s)
- Paarth Kapadia
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX
- Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Andrew J. Zimolzak
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX
- Department of Medicine, Baylor College of Medicine, Houston, TX
| | | | | | | | - Umair Mushtaq
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX
- Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Usman Mir
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX
- Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Daniel R. Murphy
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX
- Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Alexis Offner
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX
- Department of Medicine, Baylor College of Medicine, Houston, TX
| | | | - Georgios Lyratzopoulos
- Epidemiology of Cancer Healthcare and Outcomes, Institute of Epidemiology and Health Care, University College London, London, United Kingdom
| | | | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX
- Department of Medicine, Baylor College of Medicine, Houston, TX
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4
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Krenitsky NM, Perez-Urbano I, Goffman D. Diagnostic Errors in Obstetric Morbidity and Mortality: Methods for and Challenges in Seeking Diagnostic Excellence. J Clin Med 2024; 13:4245. [PMID: 39064285 PMCID: PMC11278303 DOI: 10.3390/jcm13144245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2024] [Revised: 07/14/2024] [Accepted: 07/16/2024] [Indexed: 07/28/2024] Open
Abstract
Pregnancy-related morbidity and mortality remain high across the United States, with the majority of deaths being deemed preventable. Misdiagnosis and delay in diagnosis are thought to be significant contributors to preventable harm. These diagnostic errors in obstetrics are understudied. Presented here are five selected research methods to ascertain the rates of and harm associated with diagnostic errors and the pros and cons of each. These methodologies include clinicopathologic autopsy studies, retrospective chart reviews based on clinical criteria, obstetric simulations, pregnancy-related harm case reviews, and malpractice and administrative claim database research. We then present a framework for a future study of diagnostic errors and the pursuit of diagnostic excellence in obstetrics: (1) defining and capturing diagnostic errors, (2) targeting bias in diagnostic processes, (3) implementing and monitoring safety bundles, (4) leveraging electronic health record triggers for case reviews, (5) improving diagnostic skills via simulation training, and (6) publishing error rates and reduction strategies. Evaluation of the effectiveness of this framework to ascertain diagnostic error rates, as well as its impact on patient outcomes, is required.
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Affiliation(s)
| | | | - Dena Goffman
- Department of Obstetrics and Gynecology, Vagelos College of Physicians, Columbia University, New York, NY 10023, USA; (N.M.K.); (I.P.-U.)
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5
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Carson RA, Lyles JL. Cognitive Bias in an Infant with Constipation. J Pediatr 2024; 270:113996. [PMID: 38432294 DOI: 10.1016/j.jpeds.2024.113996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 02/21/2024] [Accepted: 02/26/2024] [Indexed: 03/05/2024]
Affiliation(s)
- Rebecca A Carson
- Clinical Assistant Professor, Conway School of Nursing, The Catholic University of America, Washington, DC
| | - John L Lyles
- Assistant Professor of Pediatrics, Division of Gastroenterology/Hepatology/Nutrition, Duke University School of Medicine, Durham, NC.
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6
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Grabinski Z, Woo KM, Akindutire O, Dahn C, Nash L, Leybell I, Wang Y, Bayer D, Swartz J, Jamin C, Smith SW. Evaluation of a Structured Review Process for Emergency Department Return Visits with Admission. Jt Comm J Qual Patient Saf 2024; 50:516-527. [PMID: 38653614 DOI: 10.1016/j.jcjq.2024.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 03/10/2024] [Accepted: 03/11/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Review of emergency department (ED) revisits with admission allows the identification of improvement opportunities. Applying a health equity lens to revisits may highlight potential disparities in care transitions. Universal definitions or practicable frameworks for these assessments are lacking. The authors aimed to develop a structured methodology for this quality assurance (QA) process, with a layered equity analysis. METHODS The authors developed a classification instrument to identify potentially preventable 72-hour returns with admission (PPRA-72), accounting for directed, unrelated, unanticipated, or disease progression returns. A second review team assessed the instrument reliability. A self-reported race/ethnicity (R/E) and language algorithm was developed to minimize uncategorizable data. Disposition distribution, return rates, and PPRA-72 classifications were analyzed for disparities using Pearson chi-square and Fisher's exact tests. RESULTS The PPRA-72 rate was 4.8% for 2022 ED return visits requiring admission. Review teams achieved 93% agreement (κ = 0.51) for the binary determination of PPRA-72 vs. nonpreventable returns. There were significant differences between R/E and language in ED dispositions (p < 0.001), with more frequent admissions for the R/E White at the index visit and Other at the 72-hour return visit. Rates of return visits within 72 hours differed significantly by R/E (p < 0.001) but not by language (p = 0.156), with the R/E Black most frequent to have a 72-hour return. There were no differences between R/E (p = 0.446) or language (p = 0.248) in PPRA-72 rates. The initiative led to system improvements through informatics optimizations, triage protocols, provider feedback, and education. CONCLUSION The authors developed a review methodology for identifying improvement opportunities across ED 72-hour returns. This QA process enabled the identification of areas of disparity, with the continuous aim to develop next steps in ensuring health equity in care transitions.
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7
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Peterson KS, Chapman AB, Widanagamaachchi W, Sutton J, Ochoa B, Jones BE, Stevens V, Classen DC, Jones MM. Automating detection of diagnostic error of infectious diseases using machine learning. PLOS DIGITAL HEALTH 2024; 3:e0000528. [PMID: 38848317 PMCID: PMC11161023 DOI: 10.1371/journal.pdig.0000528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 05/07/2024] [Indexed: 06/09/2024]
Abstract
Diagnostic error, a cause of substantial morbidity and mortality, is largely discovered and evaluated through self-report and manual review, which is costly and not suitable to real-time intervention. Opportunities exist to leverage electronic health record data for automated detection of potential misdiagnosis, executed at scale and generalized across diseases. We propose a novel automated approach to identifying diagnostic divergence considering both diagnosis and risk of mortality. Our objective was to identify cases of emergency department infectious disease misdiagnoses by measuring the deviation between predicted diagnosis and documented diagnosis, weighted by mortality. Two machine learning models were trained for prediction of infectious disease and mortality using the first 24h of data. Charts were manually reviewed by clinicians to determine whether there could have been a more correct or timely diagnosis. The proposed approach was validated against manual reviews and compared using the Spearman rank correlation. We analyzed 6.5 million ED visits and over 700 million associated clinical features from over one hundred emergency departments. The testing set performances of the infectious disease (Macro F1 = 86.7, AUROC 90.6 to 94.7) and mortality model (Macro F1 = 97.6, AUROC 89.1 to 89.1) were in expected ranges. Human reviews and the proposed automated metric demonstrated positive correlations ranging from 0.231 to 0.358. The proposed approach for diagnostic deviation shows promise as a potential tool for clinicians to find diagnostic errors. Given the vast number of clinical features used in this analysis, further improvements likely need to either take greater account of data structure (what occurs before when) or involve natural language processing. Further work is needed to explain the potential reasons for divergence and to refine and validate the approach for implementation in real-world settings.
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Affiliation(s)
- Kelly S. Peterson
- Veterans Health Administration, Office of Analytics and Performance Integration, Washington D.C., District of Columbia, United States of America
- Department of Internal Medicine, Division of Epidemiology, University of Utah, Salt Lake City, Utah, United States of America
| | - Alec B. Chapman
- Department of Internal Medicine, Division of Epidemiology, University of Utah, Salt Lake City, Utah, United States of America
- Veterans Affairs Health Care System, Salt Lake City, Utah, United States of America
| | - Wathsala Widanagamaachchi
- Department of Internal Medicine, Division of Epidemiology, University of Utah, Salt Lake City, Utah, United States of America
- Veterans Affairs Health Care System, Salt Lake City, Utah, United States of America
| | - Jesse Sutton
- Veterans Affairs Health Care System, Minneapolis, Minnesota, United States of America
| | - Brennan Ochoa
- Rocky Mountain Infectious Diseases Specialists, Aurora, Colorado, United States of America
| | - Barbara E. Jones
- Veterans Affairs Health Care System, Salt Lake City, Utah, United States of America
- Division of Pulmonary & Critical Care Medicine, University of Utah, Salt Lake City, Utah, United States of America
| | - Vanessa Stevens
- Veterans Health Administration, Office of Analytics and Performance Integration, Washington D.C., District of Columbia, United States of America
- Department of Internal Medicine, Division of Epidemiology, University of Utah, Salt Lake City, Utah, United States of America
| | - David C. Classen
- Department of Internal Medicine, Division of Epidemiology, University of Utah, Salt Lake City, Utah, United States of America
| | - Makoto M. Jones
- Veterans Health Administration, Office of Analytics and Performance Integration, Washington D.C., District of Columbia, United States of America
- Department of Internal Medicine, Division of Epidemiology, University of Utah, Salt Lake City, Utah, United States of America
- Veterans Affairs Health Care System, Salt Lake City, Utah, United States of America
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8
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Radecki RP. Where Do We Go Wrong?: June 2024 Annals of Emergency Medicine Journal Club. Ann Emerg Med 2024; 83:621-623. [PMID: 38777504 DOI: 10.1016/j.annemergmed.2024.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Affiliation(s)
- Ryan P Radecki
- Department of Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand
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9
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Sloane J, Singh H, Upadhyay DK, Korukonda S, Marinez A, Giardina TD. Partnership as a Pathway to Diagnostic Excellence: The Challenges and Successes of Implementing the Safer Dx Learning Lab. Jt Comm J Qual Patient Saf 2024:S1553-7250(24)00172-7. [PMID: 38944572 DOI: 10.1016/j.jcjq.2024.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 05/23/2024] [Accepted: 05/24/2024] [Indexed: 07/01/2024]
Abstract
BACKGROUND Learning health system (LHS) approaches could potentially help health care organizations (HCOs) identify and address diagnostic errors. However, few such programs exist, and their implementation is poorly understood. METHODS The authors conducted a qualitative evaluation of the Safer Dx Learning Lab, a partnership between a health system and a research team, to identify and learn from diagnostic errors and improve diagnostic safety at an organizational level. The research team conducted virtual interviews to solicit participant feedback regarding experiences with the lab, focusing specifically on implementation and sustainment issues. RESULTS Interviews of 25 members associated with the lab identified the following successes: learning and professional growth, improved workflow related to streamlining the process of reporting error cases, and a psychologically safe culture for identifying and reporting diagnostic errors. However, multiple barriers also emerged: competing priorities between clinical responsibilities and research, time-management issues related to a lack of protected time, and inadequate guidance to disseminate findings. Lessons learned included understanding the importance of obtaining buy-in from leadership and interested stakeholders, creating a psychologically safe environment for reporting cases, and the need for more protected time for clinicians to review and learn from cases. CONCLUSION Findings suggest that a learning health systems approach using partnerships between researchers and a health system affected organizational culture by prioritizing learning from diagnostic errors and encouraging clinicians to be more open to reporting. The study findings can help organizations overcome barriers to engage clinicians and inform future implementation and sustainment of similar initiatives.
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10
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Harada Y, Otaka Y, Katsukura S, Shimizu T. Effect of contextual factors on the prevalence of diagnostic errors among patients managed by physicians of the same specialty: a single-centre retrospective observational study. BMJ Qual Saf 2024; 33:386-394. [PMID: 36690471 DOI: 10.1136/bmjqs-2022-015436] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 01/13/2023] [Indexed: 01/24/2023]
Abstract
BACKGROUND There has been growing recognition that contextual factors influence the physician's cognitive processes. However, given that cognitive processes may depend on the physicians' specialties, the effects of contextual factors on diagnostic errors reported in previous studies could be confounded by difference in physicians. OBJECTIVE This study aimed to clarify whether contextual factors such as location and consultation type affect diagnostic accuracy. METHODS We reviewed the medical records of 1992 consecutive outpatients consulted by physicians from the Department of Diagnostic and Generalist Medicine in a university hospital between 1 January and 31 December 2019. Diagnostic processes were assessed using the Revised Safer Dx Instrument. Patients were categorised into three groups according to contextual factors (location and consultation type): (1) referred patients with scheduled visit to the outpatient department; (2) patients with urgent visit to the outpatient department; and (3) patients with emergency visit to the emergency room. The effect of the contextual factors on the prevalence of diagnostic errors was investigated using logistic regression analysis. RESULTS Diagnostic errors were observed in 12 of 534 referred patients with scheduled visit to the outpatient department (2.2%), 3 of 599 patients with urgent visit to the outpatient department (0.5%) and 13 of 859 patients with emergency visit to the emergency room (1.5%). Multivariable logistic regression analysis showed a significantly higher prevalence of diagnostic errors in referred patients with scheduled visit to the outpatient department than in patients with urgent visit to the outpatient department (OR 4.08, p=0.03), but no difference between patients with emergency and urgent visit to the emergency room and outpatient department, respectively. CONCLUSION Contextual factors such as consultation type may affect diagnostic errors; however, since the differences in the prevalence of diagnostic errors were small, the effect of contextual factors on diagnostic accuracy may be small in physicians working in different care settings.
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Affiliation(s)
- Yukinori Harada
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University, Mibu, Tochigi, Japan
| | - Yumi Otaka
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University, Mibu, Tochigi, Japan
| | - Shinichi Katsukura
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University, Mibu, Tochigi, Japan
| | - Taro Shimizu
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University, Mibu, Tochigi, Japan
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11
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Bradford A, Meyer AND, Khan S, Giardina TD, Singh H. Diagnostic error in mental health: a review. BMJ Qual Saf 2024:bmjqs-2023-016996. [PMID: 38575311 DOI: 10.1136/bmjqs-2023-016996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 03/04/2024] [Indexed: 04/06/2024]
Abstract
Diagnostic errors are associated with patient harm and suboptimal outcomes. Despite national scientific efforts to advance definition, measurement and interventions for diagnostic error, diagnosis in mental health is not well represented in this ongoing work. We aimed to summarise the current state of research on diagnostic errors in mental health and identify opportunities to align future research with the emerging science of diagnostic safety. We review conceptual considerations for defining and measuring diagnostic error, the application of these concepts to mental health settings, and the methods and subject matter focus of recent studies of diagnostic error in mental health. We found that diagnostic error is well understood to be a problem in mental healthcare. Although few studies used clear definitions or frameworks for understanding diagnostic error in mental health, several studies of missed, wrong, delayed and disparate diagnosis of common mental disorders have identified various avenues for future research and development. Nevertheless, a lack of clear consensus on how to conceptualise, define and measure errors in diagnosis will pose a barrier to advancement. Further research should focus on identifying preventable missed opportunities in the diagnosis of mental disorders, which may uncover generalisable opportunities for improvement.
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Affiliation(s)
- Andrea Bradford
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, Texas, USA
| | - Ashley N D Meyer
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, Texas, USA
| | - Sundas Khan
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, Texas, USA
| | - Traber D Giardina
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, Texas, USA
| | - Hardeep Singh
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, Texas, USA
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12
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Koo MM, Mounce LTA, Rafiq M, Callister MEJ, Singh H, Abel GA, Lyratzopoulos G. Guideline concordance for timely chest imaging after new presentations of dyspnoea or haemoptysis in primary care: a retrospective cohort study. Thorax 2024; 79:236-244. [PMID: 37620048 DOI: 10.1136/thorax-2022-219509] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 07/08/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND Guidelines recommend urgent chest X-ray for newly presenting dyspnoea or haemoptysis but there is little evidence about their implementation. METHODS We analysed linked primary care and hospital imaging data for patients aged 30+ years newly presenting with dyspnoea or haemoptysis in primary care during April 2012 to March 2017. We examined guideline-concordant management, defined as General Practitioner-ordered chest X-ray/CT carried out within 2 weeks of symptomatic presentation, and variation by sociodemographic characteristic and relevant medical history using logistic regression. Additionally, among patients diagnosed with cancer we described time to diagnosis, diagnostic route and stage at diagnosis by guideline-concordant status. RESULTS In total, 22 560/162 161 (13.9%) patients with dyspnoea and 4022/8120 (49.5%) patients with haemoptysis received guideline-concordant imaging within the recommended 2-week period. Patients with recent chest imaging pre-presentation were much less likely to receive imaging (adjusted OR 0.16, 95% CI 0.14-0.18 for dyspnoea, and adjusted OR 0.09, 95% CI 0.06-0.11 for haemoptysis). History of chronic obstructive pulmonary disease/asthma was also associated with lower odds of guideline concordance (dyspnoea: OR 0.234, 95% CI 0.225-0.242 and haemoptysis: 0.88, 0.79-0.97). Guideline-concordant imaging was lower among dyspnoea presenters with prior heart failure; current or ex-smokers; and those in more socioeconomically disadvantaged groups.The likelihood of lung cancer diagnosis within 12 months was greater among the guideline-concordant imaging group (dyspnoea: 1.1% vs 0.6%; haemoptysis: 3.5% vs 2.7%). CONCLUSION The likelihood of receiving urgent imaging concords with the risk of subsequent cancer diagnosis. Nevertheless, large proportions of dyspnoea and haemoptysis presenters do not receive prompt chest imaging despite being eligible, indicating opportunities for earlier lung cancer diagnosis.
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Affiliation(s)
- Minjoung Monica Koo
- Epidemiology of Cancer Healthcare and Outcomes (ECHO) Group, Dept. of Behavioural Science and Health, Institute of Epidemiology & Health Care (IEHC), UCL, London, UK
| | - Luke T A Mounce
- Exeter Collaboration for Academic Primary Care (APEx), University of Exeter Medical School, Exeter, UK
| | - Meena Rafiq
- Epidemiology of Cancer Healthcare and Outcomes (ECHO) Group, Dept. of Behavioural Science and Health, Institute of Epidemiology & Health Care (IEHC), UCL, London, UK
| | | | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas, USA
- Health Services Research Section, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Gary A Abel
- Exeter Collaboration for Academic Primary Care (APEx), University of Exeter Medical School, Exeter, UK
| | - Georgios Lyratzopoulos
- Epidemiology of Cancer Healthcare and Outcomes (ECHO) Group, Dept. of Behavioural Science and Health, Institute of Epidemiology & Health Care (IEHC), UCL, London, UK
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13
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Auerbach AD, Lee TM, Hubbard CC, Ranji SR, Raffel K, Valdes G, Boscardin J, Dalal AK, Harris A, Flynn E, Schnipper JL. Diagnostic Errors in Hospitalized Adults Who Died or Were Transferred to Intensive Care. JAMA Intern Med 2024; 184:164-173. [PMID: 38190122 PMCID: PMC10775080 DOI: 10.1001/jamainternmed.2023.7347] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 11/07/2023] [Indexed: 01/09/2024]
Abstract
Importance Diagnostic errors contribute to patient harm, though few data exist to describe their prevalence or underlying causes among medical inpatients. Objective To determine the prevalence, underlying cause, and harms of diagnostic errors among hospitalized adults transferred to an intensive care unit (ICU) or who died. Design, Setting, and Participants Retrospective cohort study conducted at 29 academic medical centers in the US in a random sample of adults hospitalized with general medical conditions and who were transferred to an ICU, died, or both from January 1 to December 31, 2019. Each record was reviewed by 2 trained clinicians to determine whether a diagnostic error occurred (ie, missed or delayed diagnosis), identify diagnostic process faults, and classify harms. Multivariable models estimated association between process faults and diagnostic error. Opportunity for diagnostic error reduction associated with each fault was estimated using the adjusted proportion attributable fraction (aPAF). Data analysis was performed from April through September 2023. Main Outcomes and Measures Whether or not a diagnostic error took place, the frequency of underlying causes of errors, and harms associated with those errors. Results Of 2428 patient records at 29 hospitals that underwent review (mean [SD] patient age, 63.9 [17.0] years; 1107 [45.6%] female and 1321 male individuals [54.4%]), 550 patients (23.0%; 95% CI, 20.9%-25.3%) had experienced a diagnostic error. Errors were judged to have contributed to temporary harm, permanent harm, or death in 436 patients (17.8%; 95% CI, 15.9%-19.8%); among the 1863 patients who died, diagnostic error was judged to have contributed to death in 121 (6.6%; 95% CI, 5.3%-8.2%). In multivariable models examining process faults associated with any diagnostic error, patient assessment problems (aPAF, 21.4%; 95% CI, 16.4%-26.4%) and problems with test ordering and interpretation (aPAF, 19.9%; 95% CI, 14.7%-25.1%) had the highest opportunity to reduce diagnostic errors; similar ranking was seen in multivariable models examining harmful diagnostic errors. Conclusions and Relevance In this cohort study, diagnostic errors in hospitalized adults who died or were transferred to the ICU were common and associated with patient harm. Problems with choosing and interpreting tests and the processes involved with clinician assessment are high-priority areas for improvement efforts.
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Affiliation(s)
- Andrew D. Auerbach
- Division of Hospital Medicine, Department of Medicine, University of California San Francisco
| | - Tiffany M. Lee
- Division of Hospital Medicine, Department of Medicine, University of California San Francisco
| | - Colin C. Hubbard
- Division of Hospital Medicine, Department of Medicine, University of California San Francisco
| | - Sumant R. Ranji
- Division of Hospital Medicine, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Katie Raffel
- Department of Medicine, University of Colorado School of Medicine, Denver
| | - Gilmer Valdes
- Department of Radiation Oncology, University of California San Francisco
| | - John Boscardin
- Division of Geriatrics, Department of Medicine, University of California San Francisco
| | - Anuj K. Dalal
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, and Harvard Medical School, Boston, Massachusetts
| | | | | | - Jeffrey L. Schnipper
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, and Harvard Medical School, Boston, Massachusetts
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Ali KJ, Goeschel CA, DeLia DM, Blackall LM, Singh H. The PRIDx framework to engage payers in reducing diagnostic errors in healthcare. Diagnosis (Berl) 2024; 11:17-24. [PMID: 37795579 DOI: 10.1515/dx-2023-0042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Accepted: 08/26/2023] [Indexed: 10/06/2023]
Abstract
OBJECTIVES No framework currently exists to guide how payers and providers can collaboratively develop and implement incentives to improve diagnostic safety. We conducted a literature review and interviews with subject matter experts to develop a multi-component 'Payer Relationships for Improving Diagnoses (PRIDx)' framework, that could be used to engage payers in diagnostic safety efforts. CONTENT The PRIDx framework, 1) conceptualizes diagnostic safety links to care provision, 2) illustrates ways to promote payer and provider engagement in the design and adoption of accountability mechanisms, and 3) explicates the use of data analytics. Certain approaches suggested by PRIDx were refined by subject matter expert interviewee perspectives. SUMMARY The PRIDx framework can catalyze public and private payers to take specific actions to improve diagnostic safety. OUTLOOK Implementation of the PRIDx framework requires new types of partnerships, including external support from public and private payer organizations, and requires creation of strong provider incentives without undermining providers' sense of professionalism and autonomy. PRIDx could help facilitate collaborative payer-provider approaches to improve diagnostic safety and generate research concepts, policy ideas, and potential innovations for engaging payers in diagnostic safety improvement activities.
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Affiliation(s)
- Kisha J Ali
- MedStar Institute for Quality and Safety, Columbia, MD, USA
| | - Christine A Goeschel
- MedStar Institute for Quality and Safety, Columbia, MD, USA
- Georgetown University School of Medicine, Washington, DC, USA
| | - Derek M DeLia
- Rutgers University, Bloustein School of Planning and Public Policy, New Brunswick, NJ, USA
| | | | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas, USA
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15
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Marang-van de Mheen PJ, Thomas EJ, Graber ML. How safe is the diagnostic process in healthcare? BMJ Qual Saf 2024; 33:82-85. [PMID: 37793802 DOI: 10.1136/bmjqs-2023-016496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/12/2023] [Indexed: 10/06/2023]
Affiliation(s)
- Perla J Marang-van de Mheen
- Safety & Security Science, Delft University of Technology, Faculty of Technology, Policy & Management, Delft, The Netherlands
- Centre for Safety in Healthcare, Delft University of Technology, Delft, The Netherlands
| | - Eric J Thomas
- Internal Medicine, University of Texas John P and Katherine G McGovern Medical School, Houston, Texas, USA
- The UTHealth-Memorial Hermann Center for Healthcare Quality and Safety, UTHealth, Houston, Texas, USA
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16
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Kwan JL, Calder LA, Bowman CL, MacIntyre A, Mimeault R, Honey L, Dunn C, Garber G, Singh H. Characteristics and contributing factors of diagnostic error in surgery: analysis of closed medico-legal cases and complaints in Canada. Can J Surg 2024; 67:E58-E65. [PMID: 38320779 PMCID: PMC10852193 DOI: 10.1503/cjs.003523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2023] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND Diagnostic errors lead to patient harm; however, most research has been conducted in nonsurgical disciplines. We sought to characterize diagnostic error in the pre-, intra-, and postoperative surgical phases, describe their contributing factors, and quantify their impact related to patient harm. METHODS We performed a retrospective analysis of closed medico-legal cases and complaints using a database representing more than 95% of all Canadian physicians. We included cases if they involved a legal action or complaint that closed between 2014 and 2018 and involved a diagnostic error assigned by peer expert review to a surgeon. RESULTS We identified 387 surgical cases that involved a diagnostic error. The surgical specialties most often associated with diagnostic error were general surgery (n = 151, 39.0%), gynecology (n = 71, 18.3%), and orthopedic surgery (n = 48, 12.4%), but most surgical specialties were represented. Errors occurred more often in the postoperative phase (n = 171, 44.2%) than in the pre- (n = 127, 32.8%) or intra-operative (n = 120, 31.0%) phases of surgical care. More than 80% of the contributing factors for diagnostic errors were related to providers, with clinical decision-making being the principal contributing factor. Half of the contributing factors were related to the health care team (n = 194, 50.1%), the most common of which was communication breakdown. More than half of patients involved in a surgical diagnostic error experienced at least moderate harm, with 1 in 7 cases resulting in death. CONCLUSION In our cohort, diagnostic errors occurred in most surgical disciplines and across all surgical phases of care; contributing factors were commonly attributed to provider clinical decision-making and communication breakdown. Surgical patient safety efforts should include diagnostic errors with a focus on understanding and reducing errors in surgical clinical decision-making and improving communication.
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Affiliation(s)
- Janice L Kwan
- From the Department of Medicine, Sinai Health and University of Toronto, Toronto, Ont. (Kwan); Safe Medical Care Research, Canadian Medical Protective Association, Ottawa, Ont. (Calder, Bowman, MacIntyre, Mimeault, Honey, Dunn, Garber); the Department of Emergency Medicine and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ont. (Calder); the Canadian Association of General Surgeons, Kanata, Ont. (Mimeault); the Department of Obstetrics and Gynecology, Queensway Carleton Hospital, Ottawa, Ont. (Honey); the Department of Medicine and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ont. (Garber); Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center (Singh); and Baylor College of Medicine, Houston, TX, USA (Singh).
| | - Lisa A Calder
- From the Department of Medicine, Sinai Health and University of Toronto, Toronto, Ont. (Kwan); Safe Medical Care Research, Canadian Medical Protective Association, Ottawa, Ont. (Calder, Bowman, MacIntyre, Mimeault, Honey, Dunn, Garber); the Department of Emergency Medicine and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ont. (Calder); the Canadian Association of General Surgeons, Kanata, Ont. (Mimeault); the Department of Obstetrics and Gynecology, Queensway Carleton Hospital, Ottawa, Ont. (Honey); the Department of Medicine and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ont. (Garber); Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center (Singh); and Baylor College of Medicine, Houston, TX, USA (Singh)
| | - Cara L Bowman
- From the Department of Medicine, Sinai Health and University of Toronto, Toronto, Ont. (Kwan); Safe Medical Care Research, Canadian Medical Protective Association, Ottawa, Ont. (Calder, Bowman, MacIntyre, Mimeault, Honey, Dunn, Garber); the Department of Emergency Medicine and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ont. (Calder); the Canadian Association of General Surgeons, Kanata, Ont. (Mimeault); the Department of Obstetrics and Gynecology, Queensway Carleton Hospital, Ottawa, Ont. (Honey); the Department of Medicine and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ont. (Garber); Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center (Singh); and Baylor College of Medicine, Houston, TX, USA (Singh)
| | - Anna MacIntyre
- From the Department of Medicine, Sinai Health and University of Toronto, Toronto, Ont. (Kwan); Safe Medical Care Research, Canadian Medical Protective Association, Ottawa, Ont. (Calder, Bowman, MacIntyre, Mimeault, Honey, Dunn, Garber); the Department of Emergency Medicine and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ont. (Calder); the Canadian Association of General Surgeons, Kanata, Ont. (Mimeault); the Department of Obstetrics and Gynecology, Queensway Carleton Hospital, Ottawa, Ont. (Honey); the Department of Medicine and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ont. (Garber); Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center (Singh); and Baylor College of Medicine, Houston, TX, USA (Singh)
| | - Richard Mimeault
- From the Department of Medicine, Sinai Health and University of Toronto, Toronto, Ont. (Kwan); Safe Medical Care Research, Canadian Medical Protective Association, Ottawa, Ont. (Calder, Bowman, MacIntyre, Mimeault, Honey, Dunn, Garber); the Department of Emergency Medicine and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ont. (Calder); the Canadian Association of General Surgeons, Kanata, Ont. (Mimeault); the Department of Obstetrics and Gynecology, Queensway Carleton Hospital, Ottawa, Ont. (Honey); the Department of Medicine and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ont. (Garber); Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center (Singh); and Baylor College of Medicine, Houston, TX, USA (Singh)
| | - Liisa Honey
- From the Department of Medicine, Sinai Health and University of Toronto, Toronto, Ont. (Kwan); Safe Medical Care Research, Canadian Medical Protective Association, Ottawa, Ont. (Calder, Bowman, MacIntyre, Mimeault, Honey, Dunn, Garber); the Department of Emergency Medicine and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ont. (Calder); the Canadian Association of General Surgeons, Kanata, Ont. (Mimeault); the Department of Obstetrics and Gynecology, Queensway Carleton Hospital, Ottawa, Ont. (Honey); the Department of Medicine and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ont. (Garber); Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center (Singh); and Baylor College of Medicine, Houston, TX, USA (Singh)
| | - Cynthia Dunn
- From the Department of Medicine, Sinai Health and University of Toronto, Toronto, Ont. (Kwan); Safe Medical Care Research, Canadian Medical Protective Association, Ottawa, Ont. (Calder, Bowman, MacIntyre, Mimeault, Honey, Dunn, Garber); the Department of Emergency Medicine and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ont. (Calder); the Canadian Association of General Surgeons, Kanata, Ont. (Mimeault); the Department of Obstetrics and Gynecology, Queensway Carleton Hospital, Ottawa, Ont. (Honey); the Department of Medicine and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ont. (Garber); Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center (Singh); and Baylor College of Medicine, Houston, TX, USA (Singh)
| | - Gary Garber
- From the Department of Medicine, Sinai Health and University of Toronto, Toronto, Ont. (Kwan); Safe Medical Care Research, Canadian Medical Protective Association, Ottawa, Ont. (Calder, Bowman, MacIntyre, Mimeault, Honey, Dunn, Garber); the Department of Emergency Medicine and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ont. (Calder); the Canadian Association of General Surgeons, Kanata, Ont. (Mimeault); the Department of Obstetrics and Gynecology, Queensway Carleton Hospital, Ottawa, Ont. (Honey); the Department of Medicine and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ont. (Garber); Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center (Singh); and Baylor College of Medicine, Houston, TX, USA (Singh)
| | - Hardeep Singh
- From the Department of Medicine, Sinai Health and University of Toronto, Toronto, Ont. (Kwan); Safe Medical Care Research, Canadian Medical Protective Association, Ottawa, Ont. (Calder, Bowman, MacIntyre, Mimeault, Honey, Dunn, Garber); the Department of Emergency Medicine and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ont. (Calder); the Canadian Association of General Surgeons, Kanata, Ont. (Mimeault); the Department of Obstetrics and Gynecology, Queensway Carleton Hospital, Ottawa, Ont. (Honey); the Department of Medicine and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ont. (Garber); Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center (Singh); and Baylor College of Medicine, Houston, TX, USA (Singh)
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Michelson KA, Bachur RG, Rangel SJ, Monuteaux MC, Mahajan P, Finkelstein JA. Emergency Department Volume and Delayed Diagnosis of Pediatric Appendicitis: A Retrospective Cohort Study. Ann Surg 2023; 278:833-838. [PMID: 37389457 PMCID: PMC10756921 DOI: 10.1097/sla.0000000000005972] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
OBJECTIVE To determine the association of emergency department (ED) volume of children and delayed diagnosis of appendicitis. BACKGROUND Delayed diagnosis of appendicitis is common in children. The association between ED volume and delayed diagnosis is uncertain, but diagnosis-specific experience might improve diagnostic timeliness. METHODS Using Healthcare Cost and Utilization Project 8-state data from 2014 to 2019, we studied all children with appendicitis <18 years old in all EDs. The main outcome was probable delayed diagnosis: >75% likelihood that a delay occurred based on a previously validated measure. Hierarchical models tested associations between ED volumes and delay, adjusting for age, sex, and chronic conditions. We compared complication rates by delayed diagnosis occurrence. RESULTS Among 93,136 children with appendicitis, 3,293 (3.5%) had delayed diagnosis. Each 2-fold increase in ED volume was associated with a 6.9% (95% CI: 2.2, 11.3) decreased odds of delayed diagnosis. Each 2-fold increase in appendicitis volume was associated with a 24.1% (95% CI: 21.0, 27.0) decreased odds of delay. Those with delayed diagnosis were more likely to receive intensive care [odds ratio (OR): 1.81, 95% CI: 1.48, 2.21], have perforated appendicitis (OR: 2.81, 95% CI: 2.62, 3.02), undergo abdominal abscess drainage (OR: 2.49, 95% CI: 2.16, 2.88), have multiple abdominal surgeries (OR: 2.56, 95% CI: 2.13, 3.07), or develop sepsis (OR: 2.02, 95% CI: 1.61, 2.54). CONCLUSIONS Higher ED volumes were associated with a lower risk of delayed diagnosis of pediatric appendicitis. Delay was associated with complications.
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Affiliation(s)
| | - Richard G Bachur
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
| | - Shawn J Rangel
- Department of Surgery, Boston Children's Hospital, Boston, MA
| | | | - Prashant Mahajan
- Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor, MI
| | - Jonathan A Finkelstein
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA
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18
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Michelson KA, Bachur RG, Cruz AT, Grubenhoff JA, Reeves SD, Chaudhari PP, Monuteaux MC, Dart AH, Finkelstein JA. Multicenter evaluation of a method to identify delayed diagnosis of diabetic ketoacidosis and sepsis in administrative data. Diagnosis (Berl) 2023; 10:383-389. [PMID: 37340621 PMCID: PMC10679849 DOI: 10.1515/dx-2023-0019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 06/07/2023] [Indexed: 06/22/2023]
Abstract
OBJECTIVES To derive a method of automated identification of delayed diagnosis of two serious pediatric conditions seen in the emergency department (ED): new-onset diabetic ketoacidosis (DKA) and sepsis. METHODS Patients under 21 years old from five pediatric EDs were included if they had two encounters within 7 days, the second resulting in a diagnosis of DKA or sepsis. The main outcome was delayed diagnosis based on detailed health record review using a validated rubric. Using logistic regression, we derived a decision rule evaluating the likelihood of delayed diagnosis using only characteristics available in administrative data. Test characteristics at a maximal accuracy threshold were determined. RESULTS Delayed diagnosis was present in 41/46 (89 %) of DKA patients seen twice within 7 days. Because of the high rate of delayed diagnosis, no characteristic we tested added predictive power beyond the presence of a revisit. For sepsis, 109/646 (17 %) of patients were deemed to have a delay in diagnosis. Fewer days between ED encounters was the most important characteristic associated with delayed diagnosis. In sepsis, our final model had a sensitivity for delayed diagnosis of 83.5 % (95 % confidence interval 75.2-89.9) and specificity of 61.3 % (95 % confidence interval 56.0-65.4). CONCLUSIONS Children with delayed diagnosis of DKA can be identified by having a revisit within 7 days. Many children with delayed diagnosis of sepsis may be identified using this approach with low specificity, indicating the need for manual case review.
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Affiliation(s)
| | - Richard G. Bachur
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, MA, USA
| | - Andrea T. Cruz
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Joseph A. Grubenhoff
- Section of Pediatric Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
- Children’s Hospital Colorado, Aurora, CO, USA
| | - Scott D. Reeves
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Pradip P. Chaudhari
- Division of Emergency and Transport Medicine, Children’s Hospital Los Angeles, Los Angeles, CA, USA
- Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | | | - Arianna H. Dart
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, MA, USA
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19
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Murphy DR, Zimolzak AJ, Upadhyay DK, Wei L, Jolly P, Offner A, Sittig DF, Korukonda S, Rekha RM, Singh H. Developing electronic clinical quality measures to assess the cancer diagnostic process. J Am Med Inform Assoc 2023; 30:1526-1531. [PMID: 37257883 PMCID: PMC10436145 DOI: 10.1093/jamia/ocad089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 04/12/2023] [Accepted: 05/08/2023] [Indexed: 06/02/2023] Open
Abstract
OBJECTIVE Measures of diagnostic performance in cancer are underdeveloped. Electronic clinical quality measures (eCQMs) to assess quality of cancer diagnosis could help quantify and improve diagnostic performance. MATERIALS AND METHODS We developed 2 eCQMs to assess diagnostic evaluation of red-flag clinical findings for colorectal (CRC; based on abnormal stool-based cancer screening tests or labs suggestive of iron deficiency anemia) and lung (abnormal chest imaging) cancer. The 2 eCQMs quantified rates of red-flag follow-up in CRC and lung cancer using electronic health record data repositories at 2 large healthcare systems. Each measure used clinical data to identify abnormal results, evidence of appropriate follow-up, and exclusions that signified follow-up was unnecessary. Clinicians reviewed 100 positive and 20 negative randomly selected records for each eCQM at each site to validate accuracy and categorized missed opportunities related to system, provider, or patient factors. RESULTS We implemented the CRC eCQM at both sites, while the lung cancer eCQM was only implemented at the VA due to lack of structured data indicating level of cancer suspicion on most chest imaging results at Geisinger. For the CRC eCQM, the rate of appropriate follow-up was 36.0% (26 746/74 314 patients) in the VA after removing clinical exclusions and 41.1% at Geisinger (1009/2461 patients; P < .001). Similarly, the rate of appropriate evaluation for lung cancer in the VA was 61.5% (25 166/40 924 patients). Reviewers most frequently attributed missed opportunities at both sites to provider factors (84 of 157). CONCLUSIONS We implemented 2 eCQMs to evaluate the diagnostic process in cancer at 2 large health systems. Health care organizations can use these eCQMs to monitor diagnostic performance related to cancer.
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Affiliation(s)
- Daniel R Murphy
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Andrew J Zimolzak
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Divvy K Upadhyay
- Division of Quality, Safety and Patient Experience, Geisinger, Danville, Pennsylvania, USA
| | - Li Wei
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Preeti Jolly
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Alexis Offner
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Dean F Sittig
- Department of Clinical and Health Informatics, The University of Texas Health Science Center at Houston’s School of Biomedical Informatics, Houston, Texas, USA
- The UT-Memorial Hermann Center for Healthcare Quality & Safety, Houston, Texas, USA
| | - Saritha Korukonda
- Investigator-Initiated Research Operations, Geisinger, Danville, Pennsylvania, USA
| | - Riyaa Murugaesh Rekha
- Division of Quality, Safety and Patient Experience, Geisinger, Danville, Pennsylvania, USA
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
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Trumbull DA, Braschi EL, Jain A, Southwick FS, Parsons AS, Radhakrishnan NS. Lessons in clinical reasoning - pitfalls, myths, and pearls: a case of crushing, substernal chest pain. Diagnosis (Berl) 2023; 10:316-321. [PMID: 37441731 DOI: 10.1515/dx-2022-0017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 04/25/2023] [Indexed: 07/15/2023]
Abstract
OBJECTIVES Diagnostic error is not uncommon and diagnostic accuracy can be improved with the use of problem representation, pre-test probability, and Bayesian analysis for improved clinical reasoning. CASE PRESENTATION A 48-year-old female presented as a transfer from another Emergency Department (ED) to our ED with crushing, substernal pain associated with dyspnea, diaphoresis, nausea, and a tingling sensation down both arms with radiation to the back and neck. Troponins were elevated along with an abnormal electrocardiogram. A negative myocardial perfusion scan led to the patient's discharge. The patient presented to the ED 10 days later with an anterior ST-elevation myocardial infarction. CONCLUSIONS An overemphasis on a single testing modality led to diagnostic error and a severe event. The use of pre-test probabilities guided by history-taking can lead to improved interpretation of test results, ultimately improving diagnostic accuracy and preventing serious medical errors.
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Affiliation(s)
| | - Erica L Braschi
- University of Florida College of Medicine, Gainesville, FL, USA
| | - Ankur Jain
- Baptist Heart Specialists, Jacksonville, FL, USA
| | | | - Andrew S Parsons
- Section of Hospital Medicine, Department of Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
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21
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Zhou Y, Singh H, Hamilton W, Archer S, Tan S, Brimicombe J, Lyratzopoulos G, Walter FM. Improving the diagnostic process for patients with possible bladder and kidney cancer: a mixed-methods study to identify potential missed diagnostic opportunities. Br J Gen Pract 2023; 73:e575-e585. [PMID: 37253628 PMCID: PMC10242858 DOI: 10.3399/bjgp.2022.0602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 02/03/2023] [Accepted: 02/28/2023] [Indexed: 06/01/2023] Open
Abstract
BACKGROUND Patients with bladder and kidney cancer may experience diagnostic delays. AIM To identify patterns of suboptimal care and contributors of potential missed diagnostic opportunities (MDOs). DESIGN AND SETTING Prospective, mixed-methods study recruiting participants from nine general practices in Eastern England between June 2018 and October 2019. METHOD Patients with possible bladder and kidney cancer were identified using eligibility criteria based on National Institute for Health and Care Excellence (NICE) guidelines for suspected cancer. Primary care records were reviewed at recruitment and at 1 year for data on symptoms, tests, referrals, and diagnosis. Referral predictors were examined using logistic regression. Semi-structured interviews were undertaken with 15 patients to explore their experiences of the diagnostic process, and these were analysed thematically. RESULTS Participants (n = 940) were mostly female (n = 657, 69.9%), with a median age of 71 years (interquartile range 64-77 years). In total, 268 (28.5%) received a referral and 465 (48.5%) had a final diagnosis of urinary tract infection (UTI). There were 33 (3.5%) patients who were diagnosed with cancer, including prostate (n = 17), bladder (n = 7), and upper urothelial tract (n = 1) cancers. Among referred patients, those who had a final diagnosis of UTI had the longest time to referral (median 81.5 days). Only one-third of patients with recurrent UTIs were referred despite meeting NICE referral guidelines. Qualitative findings revealed barriers during the diagnostic process, including inadequate clinical examination, female patients given repeated antibiotics without clinical reviews, and suboptimal communication of test results to patients. CONCLUSION Older females with UTIs might be at increased risk of MDOs for cancer. Targeting barriers during the initial diagnostic assessment and follow-up might improve quality of diagnosis.
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Affiliation(s)
- Yin Zhou
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX, US
| | | | - Stephanie Archer
- Department of Public Health and Primary Care, University of Cambridge, Cambridge and Department of Psychology, University of Cambridge, Cambridge, UK
| | - Sapphire Tan
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - James Brimicombe
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Georgios Lyratzopoulos
- Epidemiology of Cancer Healthcare and Outcomes (ECHO), Department of Behavioural Science and Health, Institute of Epidemiology and Health Care (IEHC), University College London, London, UK
| | - Fiona M Walter
- Department of Public Health and Primary Care, University of Cambridge, Cambridge and Wolfson Institute of Population Health, Queen Mary University of London, London, UK
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Congdon M, Rauch B, Carroll B, Costello A, Chua WD, Fairchild V, Fatemi Y, Greenfield ME, Herchline D, Howard A, Khan A, Lamberton CE, McAndrew L, Hart J, Shaw KN, Rasooly IR. Opportunities for Diagnostic Improvement Among Pediatric Hospital Readmissions. Hosp Pediatr 2023; 13:563-571. [PMID: 37271791 PMCID: PMC10330757 DOI: 10.1542/hpeds.2023-007157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
OBJECTIVES Diagnostic errors, termed "missed opportunities for improving diagnosis" (MOIDs), are known sources of harm in children but have not been well characterized in pediatric hospital medicine. Our objectives were to systematically identify and describe MOIDs among general pediatric patients who experienced hospital readmission, outline improvement opportunities, and explore factors associated with increased risk of MOID. PATIENTS AND METHODS Our retrospective cohort study included unplanned readmissions within 15 days of discharge from a freestanding children's hospital (October 2018-September 2020). Health records from index admissions and readmissions were independently reviewed and discussed by practicing inpatient physicians to identify MOIDs using an established instrument, SaferDx. MOIDs were evaluated using a diagnostic-specific tool to identify improvement opportunities within the diagnostic process. RESULTS MOIDs were identified in 22 (6.3%) of 348 readmissions. Opportunities for improvement included: delay in considering the correct diagnosis (n = 11, 50%) and failure to order needed test(s) (n = 10, 45%). Patients with MOIDs were older (median age: 3.8 [interquartile range 1.5-11.2] vs 1.0 [0.3-4.9] years) than patients without MOIDs but similar in sex, primary language, race, ethnicity, and insurance type. We did not identify conditions associated with higher risk of MOID. Lower respiratory tract infections accounted for 26% of admission diagnoses but only 1 (4.5%) case of MOID. CONCLUSIONS Standardized review of pediatric readmissions identified MOIDs and opportunities for improvement within the diagnostic process, particularly in clinician decision-making. We identified conditions with low incidence of MOID. Further work is needed to better understand pediatric populations at highest risk for MOID.
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Affiliation(s)
- Morgan Congdon
- Department of Pediatrics, Children’s Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, Pennsylvania 19104 USA
- Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, Pennsylvania, 19104 USA
| | - Bridget Rauch
- Center for Healthcare Quality and Analytics, Children’s Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, Pennsylvania 19104 USA
| | - Bryn Carroll
- Department of Pediatrics, Children’s Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, Pennsylvania 19104 USA
- Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, Pennsylvania, 19104 USA
| | - Anna Costello
- Department of Pediatrics, Children’s Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, Pennsylvania 19104 USA
- Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, Pennsylvania, 19104 USA
| | - Winona D. Chua
- Department of Pediatrics, Children’s Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, Pennsylvania 19104 USA
- Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, Pennsylvania, 19104 USA
| | - Victoria Fairchild
- Department of Pediatrics, Children’s Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, Pennsylvania 19104 USA
| | - Yasaman Fatemi
- Department of Pediatrics, Children’s Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, Pennsylvania 19104 USA
- Division of Infectious Diseases, Children’s Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, Pennsylvania 19104 USA
| | - Morgan E. Greenfield
- Department of Pediatrics, Children’s Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, Pennsylvania 19104 USA
- Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, Pennsylvania, 19104 USA
| | - Daniel Herchline
- Division of General Pediatrics, Cincinnati Children’s Hospital Medical Center
| | - Alexandra Howard
- Department of Pediatrics, Children’s Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, Pennsylvania 19104 USA
- Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, Pennsylvania, 19104 USA
| | - Amina Khan
- Center for Healthcare Quality and Analytics, Children’s Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, Pennsylvania 19104 USA
- Department of Biomedical & Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania 19104 US
| | - Courtney E. Lamberton
- Division of Critical Care Medicine, Hospital of the University of Pennsylvania and Pennsylvania Presbyterian Medical Center, Philadelphia, Pennsylvania 19104 USA
| | - Lisa McAndrew
- Department of Pediatrics, Children’s Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, Pennsylvania 19104 USA
- Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, Pennsylvania, 19104 USA
| | - Jessica Hart
- Department of Pediatrics, Children’s Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, Pennsylvania 19104 USA
- Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, Pennsylvania, 19104 USA
| | - Kathy N. Shaw
- Department of Pediatrics, Children’s Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, Pennsylvania 19104 USA
- Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, Pennsylvania, 19104 USA
| | - Irit R. Rasooly
- Department of Pediatrics, Children’s Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, Pennsylvania 19104 USA
- Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, Pennsylvania, 19104 USA
- Department of Biomedical & Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania 19104 US
- Center for Pediatric Clinical Effectiveness & PolicyLab, Children’s Hospital of Philadelphia, Roberts Center for Pediatric Research, 2716 South Street, 10th floor, Philadelphia, Pennsylvania, 19146 USA
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23
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Garber A, Garabedian P, Wu L, Lam A, Malik M, Fraser H, Bersani K, Piniella N, Motta-Calderon D, Rozenblum R, Schnock K, Griffin J, Schnipper JL, Bates DW, Dalal AK. Developing, pilot testing, and refining requirements for 3 EHR-integrated interventions to improve diagnostic safety in acute care: a user-centered approach. JAMIA Open 2023; 6:ooad031. [PMID: 37181729 PMCID: PMC10172040 DOI: 10.1093/jamiaopen/ooad031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 01/04/2023] [Accepted: 04/20/2023] [Indexed: 05/16/2023] Open
Abstract
Objective To describe a user-centered approach to develop, pilot test, and refine requirements for 3 electronic health record (EHR)-integrated interventions that target key diagnostic process failures in hospitalized patients. Materials and Methods Three interventions were prioritized for development: a Diagnostic Safety Column (DSC) within an EHR-integrated dashboard to identify at-risk patients; a Diagnostic Time-Out (DTO) for clinicians to reassess the working diagnosis; and a Patient Diagnosis Questionnaire (PDQ) to gather patient concerns about the diagnostic process. Initial requirements were refined from analysis of test cases with elevated risk predicted by DSC logic compared to risk perceived by a clinician working group; DTO testing sessions with clinicians; PDQ responses from patients; and focus groups with clinicians and patient advisors using storyboarding to model the integrated interventions. Mixed methods analysis of participant responses was used to identify final requirements and potential implementation barriers. Results Final requirements from analysis of 10 test cases predicted by the DSC, 18 clinician DTO participants, and 39 PDQ responses included the following: DSC configurable parameters (variables, weights) to adjust baseline risk estimates in real-time based on new clinical data collected during hospitalization; more concise DTO wording and flexibility for clinicians to conduct the DTO with or without the patient present; and integration of PDQ responses into the DSC to ensure closed-looped communication with clinicians. Analysis of focus groups confirmed that tight integration of the interventions with the EHR would be necessary to prompt clinicians to reconsider the working diagnosis in cases with elevated diagnostic error (DE) risk or uncertainty. Potential implementation barriers included alert fatigue and distrust of the risk algorithm (DSC); time constraints, redundancies, and concerns about disclosing uncertainty to patients (DTO); and patient disagreement with the care team's diagnosis (PDQ). Discussion A user-centered approach led to evolution of requirements for 3 interventions targeting key diagnostic process failures in hospitalized patients at risk for DE. Conclusions We identify challenges and offer lessons from our user-centered design process.
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Affiliation(s)
- Alison Garber
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Pamela Garabedian
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Lindsey Wu
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Alyssa Lam
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Maria Malik
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Hannah Fraser
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Kerrin Bersani
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Nicholas Piniella
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Daniel Motta-Calderon
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Ronen Rozenblum
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Kumiko Schnock
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | | | - Jeffrey L Schnipper
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - David W Bates
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Anuj K Dalal
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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24
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van Sassen C, Mamede S, Bos M, van den Broek W, Bindels P, Zwaan L. Do malpractice claim clinical case vignettes enhance diagnostic accuracy and acceptance in clinical reasoning education during GP training? BMC MEDICAL EDUCATION 2023; 23:474. [PMID: 37365590 DOI: 10.1186/s12909-023-04448-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 06/14/2023] [Indexed: 06/28/2023]
Abstract
BACKGROUND Using malpractice claims cases as vignettes is a promising approach for improving clinical reasoning education (CRE), as malpractice claims can provide a variety of content- and context-rich examples. However, the effect on learning of adding information about a malpractice claim, which may evoke a deeper emotional response, is not yet clear. This study examined whether knowing that a diagnostic error resulted in a malpractice claim affects diagnostic accuracy and self-reported confidence in the diagnosis of future cases. Moreover, suitability of using erroneous cases with and without a malpractice claim for CRE, as judged by participants, was evaluated. METHODS In the first session of this two-phased, within-subjects experiment, 81 first-year residents of general practice (GP) were exposed to both erroneous cases with (M) and erroneous cases without (NM) malpractice claim information, derived from a malpractice claims database. Participants rated suitability of the cases for CRE on a five-point Likert scale. In the second session, one week later, participants solved four different cases with the same diagnoses. Diagnostic accuracy was measured with three questions, scored on a 0-1 scale: (1) What is your next step? (2) What is your differential diagnosis? (3) What is your most probable diagnosis and what is your level of certainty on this? Both subjective suitability and diagnostic accuracy scores were compared between the versions (M and NM) using repeated measures ANOVA. RESULTS There were no differences in diagnostic accuracy parameters (M vs. NM next step: 0.79 vs. 0.77, p = 0.505; differential diagnosis 0.68 vs. 0.75, p = 0.072; most probable diagnosis 0.52 vs. 0.57, p = 0.216) and self-reported confidence (53.7% vs. 55.8% p = 0.390) of diagnoses previously seen with or without malpractice claim information. Subjective suitability- and complexity scores for the two versions were similar (suitability: 3.68 vs. 3.84, p = 0.568; complexity 3.71 vs. 3.88, p = 0.218) and significantly increased for higher education levels for both versions. CONCLUSION The similar diagnostic accuracy rates between cases studied with or without malpractice claim information suggests both versions are equally effective for CRE in GP training. Residents judged both case versions to be similarly suitable for CRE; both were considered more suitable for advanced than for novice learners.
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Affiliation(s)
- Charlotte van Sassen
- Department of General Practice, Erasmus Medical Center, Rotterdam, The Netherlands.
- Institute of Medical Education Research Rotterdam (iMERR), Erasmus Medical Center, Rotterdam, The Netherlands.
| | - Silvia Mamede
- Institute of Medical Education Research Rotterdam (iMERR), Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Psychology, Education and Child Studies, Erasmus School of Social and Behavioral Sciences, Rotterdam, The Netherlands
| | - Michiel Bos
- Department of General Practice, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Walter van den Broek
- Institute of Medical Education Research Rotterdam (iMERR), Erasmus Medical Center, Rotterdam, The Netherlands
| | - Patrick Bindels
- Department of General Practice, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Laura Zwaan
- Institute of Medical Education Research Rotterdam (iMERR), Erasmus Medical Center, Rotterdam, The Netherlands
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25
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Alanazi A, Almutib A, Aldosari B. Physicians' Perspectives on a Multi-Dimensional Model for the Roles of Electronic Health Records in Approaching a Proper Differential Diagnosis. J Pers Med 2023; 13:jpm13040680. [PMID: 37109066 PMCID: PMC10146177 DOI: 10.3390/jpm13040680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 04/05/2023] [Accepted: 04/12/2023] [Indexed: 04/29/2023] Open
Abstract
Many healthcare organizations have adopted Electronic Health Records (EHRs) to improve the quality of care and help physicians make proper clinical decisions. The vital roles of EHRs can support the accuracy of diagnosis, suggest, and rationalize the provided care to patients. This study aims to understand the roles of EHRs in approaching proper differential diagnosis and optimizing patient safety. This study utilized a cross-sectional survey-based descriptive research design to assess physicians' perceptions of the roles of EHRs on diagnosis quality and safety. Physicians working in tertiary hospitals in Saudi Arabia were surveyed. Three hundred and fifty-one participants were included in the study, of which 61% were male. The main participants were family/general practice (22%), medicine, general (14%), and OB/GYN (12%). Overall, 66% of the participants ranked themselves as IT competent, most of the participants underwent IT self-guided learning, and 65% of the participants always used the system. The results generally reveal positive physicians' perceptions toward the roles of the EHR system on diagnosis quality and safety. There was a statistically significant relationship between user characteristics and the roles of the EHR by enhancing access to care, patient-physician encounter, clinical reasoning, diagnostic testing and consultation, follow-up, and diagnostic safety functionality. The study participants demonstrate positive perceptions of physicians toward the roles of the EHR system in approaching differential diagnosis. Yet, areas of improvement in the design and using EHRs are emphasized.
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Affiliation(s)
- Abdullah Alanazi
- Health Informatics Department, King Saud Ibn Abdulaziz University for Health Sciences, Riyadh 11481, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh 14611, Saudi Arabia
| | - Amal Almutib
- Health Informatics Department, King Saud Ibn Abdulaziz University for Health Sciences, Riyadh 11481, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh 14611, Saudi Arabia
| | - Bakheet Aldosari
- Health Informatics Department, King Saud Ibn Abdulaziz University for Health Sciences, Riyadh 11481, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh 14611, Saudi Arabia
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26
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Mahajan P, Grubenhoff JA, Cranford J, Bhatt M, Chamberlain JM, Chang T, Lyttle M, Oostenbrink R, Roland D, Rudy RM, Shaw KN, Zuniga RV, Belle A, Kuppermann N, Singh H. Types of diagnostic errors reported by paediatric emergency providers in a global paediatric emergency care research network. BMJ Open Qual 2023; 12:bmjoq-2022-002062. [PMID: 36990648 PMCID: PMC10069565 DOI: 10.1136/bmjoq-2022-002062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 03/14/2023] [Indexed: 03/30/2023] Open
Abstract
BackgroundDiagnostic errors, reframed as missed opportunities for improving diagnosis (MOIDs), are poorly understood in the paediatric emergency department (ED) setting. We investigated the clinical experience, harm and contributing factors related to MOIDs reported by physicians working in paediatric EDs.MethodsWe developed a web-based survey in which physicians participating in the international Paediatric Emergency Research Network representing five out of six WHO regions, described examples of MOIDs involving their own or a colleague’s patients. Respondents provided case summaries and answered questions regarding harm and factors contributing to the event.ResultsOf 1594 physicians surveyed, 412 (25.8%) responded (mean age=43 years (SD=9.2), 42.0% female, mean years in practice=12 (SD=9.0)). Patient presentations involving MOIDs had common undifferentiated symptoms at initial presentation, including abdominal pain (21.1%), fever (17.2%) and vomiting (16.5%). Patients were discharged from the ED with commonly reported diagnoses, including acute gastroenteritis (16.7%), viral syndrome (10.2%) and constipation (7.0%). Most reported MOIDs (65%) were detected on ED return visits (46% within 24 hours and 76% within 72 hours). The most common reported MOID was appendicitis (11.4%), followed by brain tumour (4.4%), meningitis (4.4%) and non-accidental trauma (4.1%). More than half (59.1%) of the reported MOIDs involved the patient/parent–provider encounter (eg, misinterpreted/ignored history or an incomplete/inadequate physical examination). Types of MOIDs and contributing factors did not differ significantly between countries. More than half of patients had either moderate (48.7%) or major (10%) harm due to the MOID.ConclusionsAn international cohort of paediatric ED physicians reported several MOIDs, often in children who presented to the ED with common undifferentiated symptoms. Many of these were related to patient/parent–provider interaction factors such as suboptimal history and physical examination. Physicians’ personal experiences offer an underexplored source for investigating and mitigating diagnostic errors in the paediatric ED.
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Affiliation(s)
- Prashant Mahajan
- Emergency Medicine and Paediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Joseph A Grubenhoff
- Paediatric Emergency Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
| | - Jim Cranford
- Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Maala Bhatt
- Paediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | - James M Chamberlain
- Emergency Medicine, Children's National Medical Center, Washington, District of Columbia, USA
| | - Todd Chang
- Paediatric Emergency Medicine, Children's Hospital of Los Angeles, Los Angeles, California, USA
| | - Mark Lyttle
- Paediatric Emergency Medicine, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Rianne Oostenbrink
- Paediatric Emergency Medicine, Erasmus MC-Sophia Children's Hospital, Rotterdam, UK
| | - Damian Roland
- Paediatric Emergency Medicine, University of Leicester, Leicester, UK
| | - Richard M Rudy
- Paediatric Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Kathy N Shaw
- Paediatric Emergency Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Robert Velasco Zuniga
- Paediatric Emergency Medicine, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - Apoorva Belle
- Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Nathan Kuppermann
- Emergency Medicine and Paediatrics, University of California Davis, Davis, California, USA
| | - Hardeep Singh
- Medicine - Health Services Research, Baylor College of Medicine, Houston, Texas, USA
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27
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Lipitz-Snyderman A, Chimonas S, Mailankody S, Kim M, Silva N, Kriplani A, Saltz LB, Sihag S, Tan CR, Widmar M, Zauderer M, Weingart S, Perchick W, Roman BR. Clinical value of second opinions in oncology: A retrospective review of changes in diagnosis and treatment recommendations. Cancer Med 2023; 12:8063-8072. [PMID: 36737878 PMCID: PMC10134380 DOI: 10.1002/cam4.5598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 12/08/2022] [Accepted: 12/17/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Data on the clinical value of second opinions in oncology are limited. We examined diagnostic and treatment changes resulting from second opinions and the expected impact on morbidity and prognosis. METHODS This retrospective cohort study included patients presenting in 2018 to a high-volume cancer center for second opinions about newly diagnosed colorectal, head and neck, lung, and myeloma cancers or abnormal results. Two sub-specialty physicians from each cancer type reviewed 30 medical records (120 total) using a process and detailed data collection guide meant to mitigate institutional bias. The primary outcome measure was the rate of treatment changes that were "clinically meaningful", i.e., expected to impact morbidity and/or prognosis. Among those with treatment changes, another outcome measure was the rate of clinically meaningful diagnostic changes that led to treatment change. RESULTS Of 120 cases, forty-two had clinically meaningful changes in treatment with positive expected outcomes (7 colorectal, 17 head and neck, 11 lung, 7 myeloma; 23-57%). Two patients had negative expected outcomes from having sought a second opinion, with worse short-term morbidity and unchanged long-term morbidity and prognosis. All those with positive expected outcomes had improved expected morbidity (short- and/or long-term); 11 (0-23%) also had improved expected prognosis. Nine involved a shift from treatment to observation; 21 involved eliminating or reducing the extent of surgery, compared to 6 adding surgery or increasing its extent. Of the 42 with treatment changes, 13 were due to clinically meaningful diagnostic changes (1 colorectal, 5 head and neck, 3 lung, 4 myeloma; 3%-17%) . CONCLUSIONS Second-opinion consultations sometimes add clinical value by improving expected prognoses; more often, they offer treatment de-escalations, with corresponding reductions in expected short- and/or long-term morbidity. Future research could identify subgroups of patients most likely to benefit from second opinions.
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Affiliation(s)
- Allison Lipitz-Snyderman
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Susan Chimonas
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Sham Mailankody
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Michelle Kim
- Strategy and Innovation, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Nicholas Silva
- Strategy and Innovation, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Anuja Kriplani
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Leonard B Saltz
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Smita Sihag
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Carlyn Rose Tan
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Maria Widmar
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Marjorie Zauderer
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Saul Weingart
- Rhode Island Hospital and Hasbro Children's Hospital, Providence, Rhode Island, USA
| | - Wendy Perchick
- Strategy and Innovation, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Benjamin R Roman
- Strategy and Innovation, Memorial Sloan Kettering Cancer Center, New York, New York, USA.,Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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Miller AC, Arakkal AT, Koeneman SH, Cavanaugh JE, Polgreen PM. A clinically-guided unsupervised clustering approach to recommend symptoms of disease associated with diagnostic opportunities. Diagnosis (Berl) 2023; 10:43-53. [PMID: 36127310 PMCID: PMC9934811 DOI: 10.1515/dx-2022-0044] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 08/26/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES A first step in studying diagnostic delays is to select the signs, symptoms and alternative diseases that represent missed diagnostic opportunities. Because this step is labor intensive requiring exhaustive literature reviews, we developed machine learning approaches to mine administrative data sources and recommend conditions for consideration. We propose a methodological approach to find diagnostic codes that exhibit known patterns of diagnostic delays and apply this to the diseases of tuberculosis and appendicitis. METHODS We used the IBM MarketScan Research Databases, and consider the initial symptoms of cough before tuberculosis and abdominal pain before appendicitis. We analyze diagnosis codes during healthcare visits before the index diagnosis, and use k-means clustering to recommend conditions that exhibit similar trends to the initial symptoms provided. We evaluate the clinical plausibility of the recommended conditions and the corresponding number of possible diagnostic delays based on these diseases. RESULTS For both diseases of interest, the clustering approach suggested a large number of clinically-plausible conditions to consider (e.g., fever, hemoptysis, and pneumonia before tuberculosis). The recommended conditions had a high degree of precision in terms of clinical plausibility: >70% for tuberculosis and >90% for appendicitis. Including these additional clinically-plausible conditions resulted in more than twice the number of possible diagnostic delays identified. CONCLUSIONS Our approach can mine administrative datasets to detect patterns of diagnostic delay and help investigators avoid under-identifying potential missed diagnostic opportunities. In addition, the methods we describe can be used to discover less-common presentations of diseases that are frequently misdiagnosed.
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Affiliation(s)
- Aaron C Miller
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Alan T Arakkal
- Department of Biostatistics, College of Public Health, University of Iowa, Iowa City, IA, USA
| | - Scott H Koeneman
- Department of Biostatistics, College of Public Health, University of Iowa, Iowa City, IA, USA
| | - Joseph E Cavanaugh
- Department of Biostatistics, College of Public Health, University of Iowa, Iowa City, IA, USA
| | - Philip M Polgreen
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
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29
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Schnock KO, Garber A, Fraser H, Carnie M, Schnipper JL, Dalal AK, Bates DW, Rozenblum R. Providers' and Patients' Perspectives on Diagnostic Errors in the Acute Care Setting. Jt Comm J Qual Patient Saf 2023; 49:89-97. [PMID: 36585316 DOI: 10.1016/j.jcjq.2022.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 11/16/2022] [Accepted: 11/21/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Diagnostic errors (DEs) have been studied extensively in ambulatory care, but less work has been done in the acute care setting. In this study, the authors examined health care providers' and patients' perspectives about the classification of DEs, the main causes and scope of DEs in acute care, the main gaps in current systems, and the need for innovative solutions. METHODS A qualitative mixed methods study was conducted, including semistructured interviews with health care providers and focus groups with patient advisors. Using grounded theory approach, thematic categories were derived from the interviews and focus groups. RESULTS The research team conducted interviews with 17 providers and two focus groups with seven patient advisors. Both providers and patient advisors struggled to define and describe DEs in acute care settings. Although participants agreed that DEs pose a significant risk to patient safety, their perception of the frequency of DEs was mixed. Most participants identified communication failures, lack of comfort with diagnostic uncertainty, incorrect clinical evaluation, and cognitive load as key causes of DEs. Most respondents believed that non-information technology (IT) tools and processes (for example, communication improvement strategies) could significantly reduce DEs. CONCLUSION The study findings represent an important supplement to our understanding of DEs in acute care settings and the advancement of a culture of patient safety in the context of patient-centered care and patient engagement. Health care organizations should consider the key factors identified in this study when trying to create a culture that engages clinicians and patients in reducing DEs.
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Singh H, Mushtaq U, Marinez A, Shahid U, Huebner J, McGaffigan P, Upadhyay DK. Developing the Safer Dx Checklist of Ten Safety Recommendations for Health Care Organizations to Address Diagnostic Errors. Jt Comm J Qual Patient Saf 2022; 48:581-590. [PMID: 36109312 DOI: 10.1016/j.jcjq.2022.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 08/01/2022] [Accepted: 08/02/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Most health care organizations (HCOs) find diagnostic errors hard to address. The research team developed a checklist (the Safer Dx Checklist) of 10 high-priority safety practices HCOs can use to conduct a proactive risk assessment to address diagnostic error. METHODS First, the team identified potential practices based on reviews of recent literature, reports by national and international organizations, and interviews with quality/safety leaders. Then a Delphi panel was conducted, followed by an online expert panel, to prioritize 10 practices. The prioritization process considered impact on safety and feasibility of practice implementation within a one- to three-year time frame. Finally, cognitive walkthroughs were conducted for a face-validity check with end users. The team also conducted content analysis in each step to look for themes that influenced prioritization or checklist implementation. RESULTS A total of 71 practices for prioritization were identified through the Delphi panel of 28 experts; 65% of participants reached consensus on 28 practices. A multidisciplinary panel of 10 experts helped prioritize and refine the top 10 practices, which were then developed into a checklist paired with implementation guidance. Practices included themes related to creating organizational and leadership accountability for improving diagnosis, including patients in diagnostic safety work, and developing and implementing organizational infrastructure for measurement and improvement activities. Qualitative analysis revealed insights for implementation. End users at three different HCOs helped refine implementation guidance for the checklist. CONCLUSION The researchers identified 10 safety practices to help organizations conduct a proactive, systematic assessment of risks to timely and accurate diagnosis. The Safer Dx Checklist can enable HCOs to begin implementing strategies to address diagnostic error.
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Brady PW, Marshall TL, Walsh KE. Promoting Action on Diagnostic Safety: The Safer Dx Checklist. Jt Comm J Qual Patient Saf 2022; 48:559-560. [PMID: 36155177 DOI: 10.1016/j.jcjq.2022.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Malik MA, Motta-Calderon D, Piniella N, Garber A, Konieczny K, Lam A, Plombon S, Carr K, Yoon C, Griffin J, Lipsitz S, Schnipper JL, Bates DW, Dalal AK. A structured approach to EHR surveillance of diagnostic error in acute care: an exploratory analysis of two institutionally-defined case cohorts. Diagnosis (Berl) 2022; 9:446-457. [PMID: 35993878 PMCID: PMC9651987 DOI: 10.1515/dx-2022-0032] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 07/12/2022] [Indexed: 12/29/2022]
Abstract
OBJECTIVES To test a structured electronic health record (EHR) case review process to identify diagnostic errors (DE) and diagnostic process failures (DPFs) in acute care. METHODS We adapted validated tools (Safer Dx, Diagnostic Error Evaluation Research [DEER] Taxonomy) to assess the diagnostic process during the hospital encounter and categorized 13 postulated e-triggers. We created two test cohorts of all preventable cases (n=28) and an equal number of randomly sampled non-preventable cases (n=28) from 365 adult general medicine patients who expired and underwent our institution's mortality case review process. After excluding patients with a length of stay of more than one month, each case was reviewed by two blinded clinicians trained in our process and by an expert panel. Inter-rater reliability was assessed. We compared the frequency of DE contributing to death in both cohorts, as well as mean DPFs and e-triggers for DE positive and negative cases within each cohort. RESULTS Twenty-seven (96.4%) preventable and 24 (85.7%) non-preventable cases underwent our review process. Inter-rater reliability was moderate between individual reviewers (Cohen's kappa 0.41) and substantial with the expert panel (Cohen's kappa 0.74). The frequency of DE contributing to death was significantly higher for the preventable compared to the non-preventable cohort (56% vs. 17%, OR 6.25 [1.68, 23.27], p<0.01). Mean DPFs and e-triggers were significantly and non-significantly higher for DE positive compared to DE negative cases in each cohort, respectively. CONCLUSIONS We observed substantial agreement among final consensus and expert panel reviews using our structured EHR case review process. DEs contributing to death associated with DPFs were identified in institutionally designated preventable and non-preventable cases. While e-triggers may be useful for discriminating DE positive from DE negative cases, larger studies are required for validation. Our approach has potential to augment institutional mortality case review processes with respect to DE surveillance.
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Affiliation(s)
- Maria A. Malik
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Daniel Motta-Calderon
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Nicholas Piniella
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Alison Garber
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Kaitlyn Konieczny
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Alyssa Lam
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Savanna Plombon
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Kevin Carr
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Catherine Yoon
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | | | - Stuart Lipsitz
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Jeffrey L. Schnipper
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - David W. Bates
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Anuj K. Dalal
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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Giardina TD, Shahid U, Mushtaq U, Upadhyay DK, Marinez A, Singh H. Creating a Learning Health System for Improving Diagnostic Safety: Pragmatic Insights from US Health Care Organizations. J Gen Intern Med 2022; 37:3965-3972. [PMID: 35650467 PMCID: PMC9640494 DOI: 10.1007/s11606-022-07554-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 03/30/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To identify challenges and pragmatic strategies for improving diagnostic safety at an organizational level using concepts from learning health systems METHODS: We interviewed 32 safety leaders across the USA on how their organizations approach diagnostic safety. Participants were recruited through email and represented geographically diverse academic and non-academic settings. The interview included questions on culture of reporting and learning from diagnostic errors; data gathering and analysis activities; diagnostic training and educational activities; and engagement of clinical leadership, staff, patients, and families in diagnostic safety activities. We conducted an inductive content analysis of interview transcripts and two reviewers coded all data. RESULTS Of 32 participants, 12 reported having a specific program to address diagnostic errors. Multiple barriers to implement diagnostic safety activities emerged: serious concerns about psychological safety associated with diagnostic error; lack of infrastructure for measurement, monitoring, and improvement activities related to diagnosis; lack of leadership investment, which was often diverted to competing priorities related to publicly reported measures or other incentives; and lack of dedicated teams to work on diagnostic safety. Participants provided several strategies to overcome barriers including adapting trigger tools to identify safety events, engaging patients in diagnostic safety, and appointing dedicated diagnostic safety champions. CONCLUSIONS Several foundational building blocks related to learning health systems could inform organizational efforts to reduce diagnostic error. Promoting an organizational culture specific to diagnostic safety, using science and informatics to improve measurement and analysis, leadership incentives to build institutional capacity to address diagnostic errors, and patient engagement in diagnostic safety activities can enable progress.
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Affiliation(s)
- Traber D Giardina
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt) (152), Michael E. DeBakey Veterans Affairs Medical Center (MEDVAMC), Houston, TX, USA.
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA.
| | - Umber Shahid
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt) (152), Michael E. DeBakey Veterans Affairs Medical Center (MEDVAMC), Houston, TX, USA
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Umair Mushtaq
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt) (152), Michael E. DeBakey Veterans Affairs Medical Center (MEDVAMC), Houston, TX, USA
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Divvy K Upadhyay
- Division of Quality, Safety and Patient Experience, Geisinger, Danville, PA, USA
| | - Abigail Marinez
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt) (152), Michael E. DeBakey Veterans Affairs Medical Center (MEDVAMC), Houston, TX, USA
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt) (152), Michael E. DeBakey Veterans Affairs Medical Center (MEDVAMC), Houston, TX, USA
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
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Redmond S, Barwise A, Zornes S, Dong Y, Herasevich S, Pinevich Y, Soleimani J, LeMahieu A, Leppin A, Pickering B. Contributors to Diagnostic Error or Delay in the Acute Care Setting: A Survey of Clinical Stakeholders. Health Serv Insights 2022; 15:11786329221123540. [PMID: 36119635 PMCID: PMC9476244 DOI: 10.1177/11786329221123540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 08/03/2022] [Indexed: 11/16/2022] Open
Abstract
Diagnostic error or delay (DEOD) is common in the acute care setting and results in poor patient outcomes. Many factors contribute to DEOD, but little is known about how contributors may differ across acute care areas and professional roles. As part of a sequential exploratory mixed methods research study, we surveyed acute care clinical stakeholders about the frequency with which different factors contribute to DEOD. Survey respondents could also propose solutions in open text fields. N = 220 clinical stakeholders completed the survey. Care Team Interactions, Systems and Process, Patient, Provider, and Cognitive factors were perceived to contribute to DEOD with similar frequency. Organization and Infrastructure factors were perceived to contribute to DEOD significantly less often. Responses did not vary across acute care setting. Physicians perceived Cognitive factors to contribute to DEOD more frequently compared to those in other roles. Commonly proposed solutions included: technological solutions, organization level fixes, ensuring staff know and are encouraged to work to the full scope of their role, and cultivating a culture of collaboration and respect. Multiple factors contribute to DEOD with similar frequency across acute care areas, suggesting the need for a multi-pronged approach that can be applied across acute care areas.
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Affiliation(s)
- Sarah Redmond
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Amelia Barwise
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Sarah Zornes
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Yue Dong
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Svetlana Herasevich
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Yuliya Pinevich
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jalal Soleimani
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Allison LeMahieu
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic Rochester, Rochester, MN, USA
| | - Aaron Leppin
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.,Knowledge and Evaluation Research Unit (KER), Mayo Clinic, Rochester, MN, USA
| | - Brian Pickering
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
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Bradford A, Shahid U, Schiff GD, Graber ML, Marinez A, DiStabile P, Timashenka A, Jalal H, Brady PJ, Singh H. Development and Usability Testing of the Agency for Healthcare Research and Quality Common Formats to Capture Diagnostic Safety Events. J Patient Saf 2022; 18:521-525. [PMID: 35443253 PMCID: PMC9391254 DOI: 10.1097/pts.0000000000001006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES A lack of consensus around definitions and reporting standards for diagnostic errors limits the extent to which healthcare organizations can aggregate, analyze, share, and learn from these events. In response to this problem, the Agency for Healthcare Research and Quality (AHRQ) began the development of the Common Formats for Event Reporting for Diagnostic Safety Events (CFER-DS). We conducted a usability assessment of the draft CFER-DS to inform future revision and implementation. METHODS We recruited a purposive sample of quality and safety personnel working in 8 U.S. healthcare organizations. Participants were invited to use the CFER-DS to simulate reporting for a minimum of 5 cases of diagnostic safety events and then provide written and verbal qualitative feedback. Analysis focused on participants' perceptions of content validity, ease of use, and potential for implementation. RESULTS Estimated completion time was 30 to 90 minutes per event. Participants shared generally positive feedback about content coverage and item clarity but identified reporter burden as a potential concern. Participants also identified opportunities to clarify several conceptual definitions, ensure applicability across different care settings, and develop guidance to operationalize use of CFER-DS. Findings led to refinement of content and supplementary materials to facilitate implementation. CONCLUSIONS Standardized definitions of diagnostic safety events and reporting standards for contextual information and contributing factors can help capture and analyze diagnostic safety events. In addition to usability testing, additional feedback from the field will ensure that AHRQ's CFER-DS is useful to a broad range of users for learning and safety improvement.
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Affiliation(s)
- Andrea Bradford
- From the Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine
- Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Umber Shahid
- From the Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine
- Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Gordon D. Schiff
- Center for Patient Safety Research and Practice, Brigham and Women’s Hospital
- Harvard Medical School Center for Primary Care, Boston, Massachusetts
| | - Mark L. Graber
- Society to Improve Diagnosis in Medicine, Chicago, Illinois
| | - Abigail Marinez
- From the Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine
- Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Paula DiStabile
- Agency for Healthcare Research and Quality, Rockville, Maryland
| | | | - Hamid Jalal
- Agency for Healthcare Research and Quality, Rockville, Maryland
| | | | - Hardeep Singh
- From the Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine
- Department of Medicine, Baylor College of Medicine, Houston, Texas
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Thomas E. An Interview with Hardeep Singh, MD, MPH. Jt Comm J Qual Patient Saf 2022; 48:365-369. [PMID: 35787348 DOI: 10.1016/j.jcjq.2022.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Affiliation(s)
- Helen Burstin
- Council of Medical Specialty Societies, Washington, DC
| | - Karen Cosby
- Patient Care Program, Gordon and Betty Moore Foundation, Palo Alto, California
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Giardina TD, Choi DT, Upadhyay DK, Korukonda S, Scott TM, Spitzmueller C, Schuerch C, Torretti D, Singh H. Inviting patients to identify diagnostic concerns through structured evaluation of their online visit notes. J Am Med Inform Assoc 2022; 29:1091-1100. [PMID: 35348688 PMCID: PMC9093029 DOI: 10.1093/jamia/ocac036] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 02/03/2022] [Accepted: 03/08/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The 21st Century Cures Act mandates patients' access to their electronic health record (EHR) notes. To our knowledge, no previous work has systematically invited patients to proactively report diagnostic concerns while documenting and tracking their diagnostic experiences through EHR-based clinician note review. OBJECTIVE To test if patients can identify concerns about their diagnosis through structured evaluation of their online visit notes. METHODS In a large integrated health system, patients aged 18-85 years actively using the patient portal and seen between October 2019 and February 2020 were invited to respond to an online questionnaire if an EHR algorithm detected any recent unexpected return visit following an initial primary care consultation ("at-risk" visit). We developed and tested an instrument (Safer Dx Patient Instrument) to help patients identify concerns related to several dimensions of the diagnostic process based on notes review and recall of recent "at-risk" visits. Additional questions assessed patients' trust in their providers and their general feelings about the visit. The primary outcome was a self-reported diagnostic concern. Multivariate logistic regression tested whether the primary outcome was predicted by instrument variables. RESULTS Of 293 566 visits, the algorithm identified 1282 eligible patients, of whom 486 responded. After applying exclusion criteria, 418 patients were included in the analysis. Fifty-one patients (12.2%) identified a diagnostic concern. Patients were more likely to report a concern if they disagreed with statements "the care plan the provider developed for me addressed all my medical concerns" [odds ratio (OR), 2.65; 95% confidence interval [CI], 1.45-4.87) and "I trust the provider that I saw during my visit" (OR, 2.10; 95% CI, 1.19-3.71) and agreed with the statement "I did not have a good feeling about my visit" (OR, 1.48; 95% CI, 1.09-2.01). CONCLUSION Patients can identify diagnostic concerns based on a proactive online structured evaluation of visit notes. This surveillance strategy could potentially improve transparency in the diagnostic process.
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Affiliation(s)
- Traber D Giardina
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, and Baylor College of Medicine, Houston, Texas, USA
| | - Debra T Choi
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, and Baylor College of Medicine, Houston, Texas, USA
| | | | | | - Taylor M Scott
- 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
- 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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Marshall TL, Rinke ML, Olson APJ, Brady PW. Diagnostic Error in Pediatrics: A Narrative Review. Pediatrics 2022; 149:184823. [PMID: 35230434 DOI: 10.1542/peds.2020-045948d] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/10/2021] [Indexed: 11/24/2022] Open
Abstract
A priority topic for patient safety research is diagnostic errors. However, despite the significant growth in awareness of their unacceptably high incidence and associated harm, a relative paucity of large, high-quality studies of diagnostic error in pediatrics exists. In this narrative review, we present what is known about the incidence and epidemiology of diagnostic error in pediatrics as well as the established research methods for identifying, evaluating, and reducing diagnostic errors, including their strengths and weaknesses. Additionally, we highlight that pediatric diagnostic error remains an area in need of both innovative research and quality improvement efforts to apply learnings from a rapidly growing evidence base. We propose several key research questions aimed at addressing persistent gaps in the pediatric diagnostic error literature that focus on the foundational knowledge needed to inform effective interventions to reduce the incidence of diagnostic errors and their associated harm. Additional research is needed to better establish the epidemiology of diagnostic error in pediatrics, including identifying high-risk clinical scenarios, patient populations, and groups of diagnoses. A critical need exists for validated measures of both diagnostic errors and diagnostic processes that can be adapted for different clinical settings and standardized for use across varying institutions. Pediatric researchers will need to work collaboratively on large-scale, high-quality studies to accomplish the ultimate goal of reducing diagnostic errors and their associated harm in children by addressing these fundamental gaps in knowledge.
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Affiliation(s)
- Trisha L Marshall
- Division of Hospital Medicine.,James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Michael L Rinke
- Department of Pediatrics, Albert Einstein College of Medicine and Children's Hospital at Montefiore, Bronx, New York
| | - Andrew P J Olson
- Departments of Medicine.,Pediatrics, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Patrick W Brady
- Division of Hospital Medicine.,James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
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Affiliation(s)
- Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey Veterans Affairs Medical Center and Baylor College of Medicine Houston, TX, USA
| | - Denise M Connor
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
- Medical Service, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Gurpreet Dhaliwal
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
- Medical Service, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
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Lurvey L, Kanter MH. Improving Diagnostic Error Detection and Analysis: The First Step on a Long Path to Diagnostic Error Prevention. Jt Comm J Qual Patient Saf 2022; 48:69-70. [DOI: 10.1016/j.jcjq.2021.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Laposata M. DIAGNOSTIC ERROR IN THE UNITED STATES: A SUMMARY OF THE REPORT OF A NATIONAL ACADEMY OF MEDICINE COMMITTEE. TRANSACTIONS OF THE AMERICAN CLINICAL AND CLIMATOLOGICAL ASSOCIATION 2022; 132:194-201. [PMID: 36196159 PMCID: PMC9480522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
This review article summarizes the conclusions of the National Academy of Medicine committee on diagnostic error. The committee deliberated during five in-person meetings and during numerous conference calls between April 2014 and April 2015. At three of the meetings, the committee invited multiple speakers to inform its deliberations. The 21 members of the committee represented a broad range of expertise related in some way to diagnostic errors, their potential causes, or their consequences. The members' specialized knowledge included patient safety, health care quality and measurement, patient engagement, health policy, health care professional education, cognitive psychology, health disparities, human factors and ergonomics, health information technology, decision analysis, nursing, radiology, anatomic pathology, laboratory medicine (clinical pathology), law, and health economics.
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Kuhrij L, Marang-van de Mheen PJ. Adding value to the diagnostic process. BMJ Qual Saf 2021; 31:489-492. [PMID: 34862315 DOI: 10.1136/bmjqs-2021-014092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2021] [Indexed: 11/03/2022]
Affiliation(s)
- Laurien Kuhrij
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, Netherlands
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Cheraghi-Sohi S, Holland F, Singh H, Danczak A, Esmail A, Morris RL, Small N, Williams R, de Wet C, Campbell SM, Reeves D. Incidence, origins and avoidable harm of missed opportunities in diagnosis: longitudinal patient record review in 21 English general practices. BMJ Qual Saf 2021; 30:977-985. [PMID: 34127547 PMCID: PMC8606447 DOI: 10.1136/bmjqs-2020-012594] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 04/04/2021] [Accepted: 04/06/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Diagnostic error is a global patient safety priority. OBJECTIVES To estimate the incidence, origins and avoidable harm of diagnostic errors in English general practice. Diagnostic errors were defined as missed opportunities to make a correct or timely diagnosis based on the evidence available (missed diagnostic opportunities, MDOs). METHOD Retrospective medical record reviews identified MDOs in 21 general practices. In each practice, two trained general practitioner reviewers independently conducted case note reviews on 100 randomly selected adult consultations performed during 2013-2014. Consultations where either reviewer identified an MDO were jointly reviewed. RESULTS Across 2057 unique consultations, reviewers agreed that an MDO was possible, likely or certain in 89 cases or 4.3% (95% CI 3.6% to 5.2%) of reviewed consultations. Inter-reviewer agreement was higher than most comparable studies (Fleiss' kappa=0.63). Sixty-four MDOs (72%) had two or more contributing process breakdowns. Breakdowns involved problems in the patient-practitioner encounter such as history taking, examination or ordering tests (main or secondary factor in 61 (68%) cases), performance and interpretation of diagnostic tests (31; 35%) and follow-up and tracking of diagnostic information (43; 48%). 37% of MDOs were rated as resulting in moderate to severe avoidable patient harm. CONCLUSIONS Although MDOs occurred in fewer than 5% of the investigated consultations, the high numbers of primary care contacts nationally suggest that several million patients are potentially at risk of avoidable harm from MDOs each year. Causes of MDOs were frequently multifactorial, suggesting the need for development and evaluation of multipronged interventions, along with policy changes to support them.
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Affiliation(s)
- Sudeh Cheraghi-Sohi
- NIHR Greater Manchester Patient Safety Translational Research Centre, The University of Manchester Faculty of Biology, Medicine and Health, Manchester, UK
- NIHR School for Primary Care Research, Manchester Academic Health Science Centre, The University of Manchester Faculty of Biology, Medicine and Health, Manchester, UK
| | - Fiona Holland
- NIHR School for Primary Care Research, Manchester Academic Health Science Centre, The University of Manchester Faculty of Biology, Medicine and Health, Manchester, UK
- Centre for Biostatistics, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas, USA
| | - Avril Danczak
- Central and South Manchester Specialty Training Programme for General Practice, Health Education England North West, Manchester, UK
| | - Aneez Esmail
- NIHR School for Primary Care Research, Manchester Academic Health Science Centre, The University of Manchester Faculty of Biology, Medicine and Health, Manchester, UK
| | - Rebecca Lauren Morris
- NIHR Greater Manchester Patient Safety Translational Research Centre, The University of Manchester Faculty of Biology, Medicine and Health, Manchester, UK
| | - Nicola Small
- NIHR School for Primary Care Research, Manchester Academic Health Science Centre, The University of Manchester Faculty of Biology, Medicine and Health, Manchester, UK
| | - Richard Williams
- NIHR Greater Manchester Patient Safety Translational Research Centre, The University of Manchester Faculty of Biology, Medicine and Health, Manchester, UK
| | - Carl de Wet
- School of Medicine, Griffith University Faculty of Health, Gold Coast, Queensland, Australia
| | - Stephen M Campbell
- NIHR Greater Manchester Patient Safety Translational Research Centre, The University of Manchester Faculty of Biology, Medicine and Health, Manchester, UK
- NIHR School for Primary Care Research, Manchester Academic Health Science Centre, The University of Manchester Faculty of Biology, Medicine and Health, Manchester, UK
| | - David Reeves
- NIHR School for Primary Care Research, Manchester Academic Health Science Centre, The University of Manchester Faculty of Biology, Medicine and Health, Manchester, UK
- Centre for Biostatistics, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
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Sawicki JG, Nystrom D, Purtell R, Good B, Chaulk D. Diagnostic error in the pediatric hospital: a narrative review. Hosp Pract (1995) 2021; 49:437-444. [PMID: 34743667 DOI: 10.1080/21548331.2021.2004040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Diagnostic error is a prevalent type of medical error that is associated with considerable patient harm and increased medical costs. The majority of literature guiding the current understanding of diagnostic error in the hospital setting is from adult studies. However, there is research to suggest this type of error is also prevalent in the pediatric specialty. OBJECTIVES The primary objective of this study was to define the current understanding of diagnostic error in the pediatric hospital through a structured literature review. METHODS We searched PubMed and identified studies focusing on three aspects of diagnostic error in pediatric hospitals: the incidence or prevalence, contributing factors, and related interventions. We used a tiered review, and a standardized electronic form to extract data from included articles. RESULTS Fifty-nine abstracts were screened and 23 full-text studies were included in the final review. Seventeen of the 23 studies focused on the incidence or prevalence, with only 3 studies investigating the utility of interventions. Most studies took place in an intensive care unit or emergency department with very few studies including only patients on the general wards. Overall, the prevalence of diagnostic error in pediatric hospitals varied greatly and depended on the measurement technique and specific hospital setting. Both healthcare system factors and individual cognitive factors were found to contribute to diagnostic error, with there being limited evidence to guide how best to mitigate the influence of these factors on the diagnostic process. CONCLUSION The general knowledge of diagnostic error in pediatric hospital settings is limited. Future work should incorporate structured frameworks to measure diagnostic errors and examine clinicians' diagnostic processes in real-time to help guide effective hospital-wide interventions.
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Affiliation(s)
- Jonathan G Sawicki
- Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Daniel Nystrom
- Clinical Risk Management, Intermountain Healthcare, Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Rebecca Purtell
- Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Brian Good
- Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - David Chaulk
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
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Shafer G, Gautham KS. Diagnostic Error: Why Now? Crit Care Clin 2021; 38:1-10. [PMID: 34794623 DOI: 10.1016/j.ccc.2021.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Diagnostic errors remain relatively understudied and underappreciated. They are particularly concerning in the intensive care unit, where they are more likely to result in harm to patients. There is a lack of consensus on the definition of diagnostic error, and current methods to quantify diagnostic error have numerous limitations as noted in the sentinel report by the National Academy of Medicine. Although definitive definition and measurement remain elusive goals, increasing our understanding of diagnostic error is crucial if we are to make progress in reducing the incidence and harm caused by errors in diagnosis.
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Affiliation(s)
- Grant Shafer
- Division of Neonatology, Children's Hospital of Orange County, 1201 West La Veta Avenue, Orange, CA 92868, USA.
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Abstract
Epidemiologic studies of diagnostic error in the intensive care unit (ICU) consist mostly of descriptive autopsy series. In these studies, rates of diagnostic errors are approximately 5% to 10%. Recently validated methods for retrospectively measuring error have expanded our understanding of the scope of the problem. These alternative measurement strategies have yielded similar estimates for the frequency of diagnostic error in the ICU. Although there is a fair understanding of the frequency of errors, further research is needed to better define the risk factors for diagnostic error in the ICU.
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Affiliation(s)
- Paul A Bergl
- Department of Critical Care, Gundersen Lutheran Medical Center, 1900 South Avenue, Mail Stop LM3-001, La Crosse, WI 54601, USA; Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
| | - Yan Zhou
- Department of Critical Care Medicine, Geisinger Medical Center, 100 N Academy Avenue, Danville, PA 17822, USA; Geisinger Commonwealth School of Medicine, Scranton, PA, USA
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Haddad M, Sheybani F, Naderi H, Sasan MS, Najaf Najafi M, Sedighi M, Seddigh A. Errors in Diagnosing Infectious Diseases: A Physician Survey. Front Med (Lausanne) 2021; 8:779454. [PMID: 34869499 PMCID: PMC8635483 DOI: 10.3389/fmed.2021.779454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Accepted: 10/25/2021] [Indexed: 12/01/2022] Open
Abstract
Background: Infectious diseases are commonly missed or misdiagnosed. Errors in diagnosing infectious diseases not only affect the patient but also the community health. Objectives: To describe our investigation on the most common errors in diagnosing infectious diseases and their causes according to the physicians' reports. Methods: Between August 2018 and February 2019, specialist physicians and residents across Mashhad, Iran were invited to participate in a survey to report errors they had made or witnessed regarding the diagnosis of infectious diseases. Results: Overall, 465 cases were reported by 315 participants. The most common infectious diseases affected by diagnostic errors were upper respiratory tract infections (URTIs) (n = 69, 14.8%), tuberculosis (TB) (n = 66, 14.1%), pleuro-pulmonary infections (n = 54, 11.6%), central nervous system (CNS) infections (n = 51, 10.9%), and urinary tract infections (n = 45, 9.6%). Errors occurred most frequently in generating a diagnostic hypothesis (n = 259, 55/7%), followed by history taking (n = 200, 43%), and physical examination (n = 191, 41/1%). Errors related to the diagnosis of TB (odds ratio [OR]: 2.4, 95% confidence interval [CI]:0.9-5.7; P value: 0.047) and intra-abdominal infections (OR: 7.2, 95% CI: 0.9-53.8; P value: 0.02) were associated with more-serious outcomes. Conclusion: A substantial proportion of errors in diagnosing infectious diseases moderately or seriously affect patients' outcomes. URTIs, TB, and pleuropulmonary infections were the most frequently reported infectious diseases involved in diagnostic error while errors related to the diagnosis of TB and intraabdominal infections were more frequently associated with poor outcomes. Therefore, contagious and potentially life-threatening infectious diseases should always be considered in the differential diagnosis of patients who present with compatible clinical syndromes.
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Affiliation(s)
- Mahboubeh Haddad
- Department of Infectious Diseases and Tropical Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Fereshte Sheybani
- Department of Infectious Diseases and Tropical Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - HamidReza Naderi
- Department of Infectious Diseases and Tropical Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mohammad Saeed Sasan
- Department of Pediatrics, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mona Najaf Najafi
- Clinical Research Unit, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Malihe Sedighi
- Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Atena Seddigh
- Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
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Lee SG, Cho H, Kim JY, Song J, Park JH. Factors affecting incorrect interpretation of abdominal computed tomography in non-traumatic patients by novice emergency physicians. Clin Exp Emerg Med 2021; 8:207-215. [PMID: 34649409 PMCID: PMC8517467 DOI: 10.15441/ceem.20.118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 11/16/2020] [Indexed: 11/23/2022] Open
Abstract
Objective Accurate interpretation of computed tomography (CT) scans is critical for patient care in the emergency department. We aimed to identify factors associated with an incorrect interpretation of abdominal CT by novice emergency residents and to analyze the characteristics of incorrectly interpreted scans. Methods This retrospective analysis of a prospective observational cohort was conducted at three urban emergency departments. Discrepancies between the interpretations by postgraduate year-1 (PGY-1) emergency residents and the final radiologists’ reports were assessed by independent adjudicators. Potential factors associated with incorrect interpretation included patient age, sex, time of interpretation, and organ category. Adjusted odds ratios (aORs) for incorrect interpretation were calculated using multivariable logistic regression analysis. Results Among 1,628 eligible cases, 270 (16.6%) were incorrect. The urinary system was the most correctly interpreted organ system (95.8%, 365/381), while the biliary tract was the most incorrectly interpreted (28.4%, 48/169). Normal CT images showed high false-positive rates of incorrect interpretation (28.2%, 96/340). Organ category was found to be a major determinant of incorrect interpretation. Using the urinary system as a reference, the aOR for incorrect interpretation of biliary tract disease was 9.20 (95% confidence interval, 5.0–16.90) and the aOR for incorrectly interpreting normal CT images was 8.47 (95% confidence interval, 4.85–14.78). Conclusion Biliary tract disease is a major factor associated with incorrect preliminary interpretations of abdominal CT scans by PGY-1 emergency residents. PGY-1 residents also showed high false-positive interpretation rates for normal CT images. Emergency residents’ training should focus on these two areas to improve abdominal CT interpretation accuracy.
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Affiliation(s)
- Seong Geun Lee
- Department of Emergency Medicine, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
| | - Hanjin Cho
- Department of Emergency Medicine, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
| | - Joo Yeong Kim
- Department of Emergency Medicine, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
| | - Juhyun Song
- Department of Emergency Medicine, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
| | - Jong-Hak Park
- Department of Emergency Medicine, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
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Kooda K, Bellolio F, Dierkhising R, Tande AJ. Defining Antibiotic Inertia: Application of a Focused Clinical Scenario Survey to Illuminate A New Target for Antimicrobial Stewardship During Transitions of Care. Clin Infect Dis 2021; 74:2050-2052. [PMID: 34596206 DOI: 10.1093/cid/ciab872] [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: 06/16/2021] [Indexed: 11/13/2022] Open
Abstract
In clinical scenario surveys, inpatient providers were more likely to continue inappropriate antibiotic therapy (OR 2.02; 95% CI 1.35-3.03, p<0.001) or broad therapy (OR 1.8; 95%CI 1.27-2.56, p=0.001) when initiated by ED providers, as compared to appropriate or narrow antibiotics, respectively. Antibiotic inertia could represent a significant antibiotic stewardship target.
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Affiliation(s)
- Kirstin Kooda
- Department of Pharmacy, Mayo Clinic, Rochester, MN, USA
| | | | - Ross Dierkhising
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN USA
| | - Aaron J Tande
- Department of Infectious Diseases, Mayo Clinic, Rochester, MN USA
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