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Mahajan P, Pai CW, Cosby KS, Mollen CJ, Shaw KN, Chamberlain JM, El-Kareh R, Ruddy RM, Alpern ER, Epstein HM, Giardina TD, Graber ML, Medford-Davis LN, Medlin RP, Upadhyay DK, Parker SJ, Singh H. Identifying trigger concepts to screen emergency department visits for diagnostic errors. Diagnosis (Berl) 2020; 8:340-346. [PMID: 33180032 DOI: 10.1515/dx-2020-0122] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 09/17/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVES The diagnostic process is a vital component of safe and effective emergency department (ED) care. There are no standardized methods for identifying or reliably monitoring diagnostic errors in the ED, impeding efforts to enhance diagnostic safety. We sought to identify trigger concepts to screen ED records for diagnostic errors and describe how they can be used as a measurement strategy to identify and reduce preventable diagnostic harm. METHODS We conducted a literature review and surveyed ED directors to compile a list of potential electronic health record (EHR) trigger (e-triggers) and non-EHR based concepts. We convened a multidisciplinary expert panel to build consensus on trigger concepts to identify and reduce preventable diagnostic harm in the ED. RESULTS Six e-trigger and five non-EHR based concepts were selected by the expert panel. E-trigger concepts included: unscheduled ED return to ED resulting in hospital admission, death following ED visit, care escalation, high-risk conditions based on symptom-disease dyads, return visits with new diagnostic/therapeutic interventions, and change of treating service after admission. Non-EHR based signals included: cases from mortality/morbidity conferences, risk management/safety office referrals, ED medical director case referrals, patient complaints, and radiology/laboratory misreads and callbacks. The panel suggested further refinements to aid future research in defining diagnostic error epidemiology in ED settings. CONCLUSIONS We identified a set of e-trigger concepts and non-EHR based signals that could be developed further to screen ED visits for diagnostic safety events. With additional evaluation, trigger-based methods can be used as tools to monitor and improve ED diagnostic performance.
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Affiliation(s)
- Prashant Mahajan
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Chih-Wen Pai
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Karen S Cosby
- Department of Emergency Medicine, Cook County Hospital (Stroger), Rush Medical College, Chicago, IL, USA
| | - Cynthia J Mollen
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kathy N Shaw
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - James M Chamberlain
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's National Medical Center, Washington, DC, USA
| | - Robert El-Kareh
- UCSD Health Department of Biomedical Informatics, University of California San Diego, La Jolla, CA, USA
| | - Richard M Ruddy
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Elizabeth R Alpern
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Helene M Epstein
- Board of Directors, Brightpoint Care, New York, NY, USA (Subsidiary, Sun River Health, Peekskill, NY, USA)
| | - Traber D Giardina
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX, USA
| | - Mark L Graber
- Society to Improve Diagnosis in Medicine, RTI International, Plymouth, MA, USA
| | | | - Richard P Medlin
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Divvy K Upadhyay
- Division of Quality, Safety and Patient Experience, Geisinger, Danville, PA, USA
| | - Sarah J Parker
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
| | - 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
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Chathampally Y, Cooper B, Wood DB, Tudor G, Gottlieb M. Evolving from Morbidity and Mortality to a Case-based Error Reduction Conference: Evidence-based Best Practices from the Council of Emergency Medicine Residency Directors. West J Emerg Med 2020; 21:231-241. [PMID: 33207171 PMCID: PMC7673891 DOI: 10.5811/westjem.2020.7.47583] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Accepted: 07/23/2020] [Indexed: 11/11/2022] Open
Abstract
Morbidity and mortality conferences are common among emergency medicine residency programs and are an important part of quality improvement initiatives. Here we review the key components of running an effective morbidity and mortality conference with a focus on goals and objectives, case identification and selection, session structure, and case presentation.
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Affiliation(s)
- Yashwant Chathampally
- The University of Texas Health Sciences Center at Houston, Department of Emergency Medicine, Houston, Texas
| | - Benjamin Cooper
- The University of Texas Health Sciences Center at Houston, Department of Emergency Medicine, Houston, Texas
| | - David B Wood
- Yale University Medical Center, Department of Emergency Medicine, New Haven, Connecticut
| | - Gregory Tudor
- University of Illinois College of Medicine at Peoria/OSF Healthcare, Department of Emergency Medicine, Peoria, Illinois
| | - Michael Gottlieb
- Rush University, Medical Center, Department of Emergency Medicine, Chicago, Illinois
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Grubenhoff JA, Ziniel SI, Cifra CL, Singhal G, McClead RE, Singh H. Pediatric Clinician Comfort Discussing Diagnostic Errors for Improving Patient Safety: A Survey. Pediatr Qual Saf 2020; 5:e259. [PMID: 32426626 PMCID: PMC7190246 DOI: 10.1097/pq9.0000000000000259] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 01/22/2020] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Meaningful conversations about diagnostic errors require safety cultures where clinicians are comfortable discussing errors openly. However, clinician comfort discussing diagnostic errors publicly and barriers to these discussions remain unexplored. We compared clinicians' comfort discussing diagnostic errors to other medical errors and identified barriers to open discussion. METHODS Pediatric clinicians at 4 hospitals were surveyed between May and June 2018. The survey assessed respondents' comfort discussing medical errors (with varying degrees of system versus individual clinician responsibility) during morbidity and mortality conferences and privately with peers. Respondents reported the most significant barriers to discussing diagnostic errors publicly. Poststratification weighting accounted for nonresponse bias; the Benjamini-Hochberg adjustment was applied to control for false discovery (significance set at P < 0.018). RESULTS Clinicians (n = 838; response rate 22.6%) were significantly less comfortable discussing all error types during morbidity and mortality conferences than privately (P < 0.004) and significantly less comfortable discussing diagnostic errors compared with other medical errors (P < 0.018). Comfort did not differ by clinician type or years in practice; clinicians at one institution were significantly less comfortable discussing diagnostic errors compared with peers at other institutions. The most frequently cited barriers to discussing diagnostic errors publicly included feeling like a bad clinician, loss of reputation, and peer judgment of knowledge base and decision-making. CONCLUSIONS Clinicians are more uncomfortable discussing diagnostic errors than other types of medical errors. The most frequent barriers involve the public perception of clinical performance. Addressing this aspect of safety culture may improve clinician participation in efforts to reduce harm from diagnostic errors.
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Affiliation(s)
- Joseph A. Grubenhoff
- From the Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Sonja I. Ziniel
- From the Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Christina L. Cifra
- Department of Pediatrics, University of Iowa Carver College of Medicine Stead Family, Iowa City, Iowa
| | - Geeta Singhal
- Department of Pediatrics, Baylor College of Medicine
| | - Richard E. McClead
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas
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Affiliation(s)
- Pat Croskerry
- MD, PhD, Dalhousie University, Critical Thinking, DME, 5849 University Avenue, PO Box 15000, Halifax, Nova Scotia, Canada, Phone: 902-494-4147, Fax: 902-494-2278
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