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Zaidi SAA, Ilyas F, Hakeem S, Feroze A, Sarfaraz S, Ali SK. Determining the psychometric properties of a written test to assess safe dental practice. BMJ Open Qual 2024; 13:e002384. [PMID: 38719519 PMCID: PMC11086408 DOI: 10.1136/bmjoq-2023-002384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Accepted: 09/11/2023] [Indexed: 05/12/2024] Open
Abstract
INTRODUCTION Safe practice in medicine and dentistry has been a global priority area in which large knowledge gaps are present.Patient safety strategies aim at preventing unintended damage to patients that can be caused by healthcare practitioners. One of the components of patient safety is safe clinical practice. Patient safety efforts will help in ensuring safe dental practice for early detection and limiting non-preventable errors.A valid and reliable instrument is required to assess the knowledge of dental students regarding patient safety. OBJECTIVE To determine the psychometric properties of a written test to assess safe dental practice in undergraduate dental students. MATERIAL AND METHODS A test comprising 42 multiple-choice questions of one-best type was administered to final year students (52) of a private dental college. Items were developed according to National Board of Medical Examiners item writing guidelines. The content of the test was determined in consultation with dental experts (either professor or associate professor). These experts had to assess each item on the test for language clarity as A: clear, B: ambiguous and relevance as 1: essential, 2: useful, not necessary, 3: not essential. Ethical approval was taken from the concerned dental college. Statistical analysis was done in SPSS V.25 in which descriptive analysis, item analysis and Cronbach's alpha were measured. RESULT The test scores had a reliability (calculated by Cronbach's alpha) of 0.722 before and 0.855 after removing 15 items. CONCLUSION A reliable and valid test was developed which will help to assess the knowledge of dental students regarding safe dental practice. This can guide medical educationist to develop or improve patient safety curriculum to ensure safe dental practice.
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Affiliation(s)
- Syed Akbar Abbas Zaidi
- Dental Education Department, Bahria University Medical and Dental College, Karachi, Pakistan
| | - Farnaz Ilyas
- Prosthodontics, Bahria University Medical and Dental College, Karachi, Pakistan
| | - Saman Hakeem
- Prosthodontics, Bahria University Medical and Dental College, Karachi, Pakistan
| | - Asher Feroze
- Health Research Advisory Board, HealthRAB, Karachi, Pakistan
| | - Shaur Sarfaraz
- Medical Education, Altamash Institute of Dental Medicine, Karachi, Pakistan
| | - Syeda Kausar Ali
- Institute of Medical Education, Jinnah Sindh Medical University, Karachi, Pakistan
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Villén T, Tung Y, Llamas R, Neria F, Carballo C, Vázquez JL, Monge D. Results of the implementation of a double-check protocol with point-of-care ultrasound for acute heart failure in the emergency department. Ultrasound J 2024; 16:25. [PMID: 38632169 PMCID: PMC11024074 DOI: 10.1186/s13089-024-00373-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 03/15/2024] [Indexed: 04/19/2024] Open
Abstract
OBJECTIVE To determine the effectiveness of a double-check protocol using Point-of-Care Ultrasound in the management of patients diagnosed with Acute Heart Failure in an Emergency Department. METHOD Prospective analytical cross-sectional observational study with patients diagnosed with Acute Heart Failure by the outgoing medical team, who undergo multi-organ ultrasound evaluation including cardiac, pulmonary, and inferior vena cava ultrasound. RESULTS 96 patients were included. An alternative diagnosis was found in 33% of them. Among the 77% where AHF diagnosis was confirmed, 73.4% had an underlying cause or condition not previously known (Left Ventricular Ejection Fraction less than 40% or moderate-severe valvulopathy). The introduction of the protocol had a clinically relevant impact on 47% of all included patients. CONCLUSIONS The implementation of a double-check protocol using POCUS, including cardiac, pulmonary, and inferior vena cava assessment in patients diagnosed with Acute Heart Failure, demonstrates a high utility in ensuring accurate diagnosis and proper classification of these patients.
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Affiliation(s)
- Tomás Villén
- School of Medicine, Universidad Francisco de Vitoria, Madrid, Spain.
| | - Yale Tung
- Internal Medicine Department, Hospital Universitario La Paz, Madrid, Spain
| | - Rafael Llamas
- Emergency Department, Hospital Universitario Reina Sofía, Córdoba, Spain
| | - Fernando Neria
- School of Medicine, Universidad Francisco de Vitoria, Madrid, Spain
| | - César Carballo
- Emergency Department, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - José Luis Vázquez
- Pediatric Intensive Care Unit, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Diana Monge
- School of Medicine, Universidad Francisco de Vitoria, Madrid, Spain
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Siepmann R, Huppertz M, Rastkhiz A, Reen M, Corban E, Schmidt C, Wilke S, Schad P, Yüksel C, Kuhl C, Truhn D, Nebelung S. The virtual reference radiologist: comprehensive AI assistance for clinical image reading and interpretation. Eur Radiol 2024:10.1007/s00330-024-10727-2. [PMID: 38627289 DOI: 10.1007/s00330-024-10727-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 02/27/2024] [Accepted: 03/08/2024] [Indexed: 04/20/2024]
Abstract
OBJECTIVES Large language models (LLMs) have shown potential in radiology, but their ability to aid radiologists in interpreting imaging studies remains unexplored. We investigated the effects of a state-of-the-art LLM (GPT-4) on the radiologists' diagnostic workflow. MATERIALS AND METHODS In this retrospective study, six radiologists of different experience levels read 40 selected radiographic [n = 10], CT [n = 10], MRI [n = 10], and angiographic [n = 10] studies unassisted (session one) and assisted by GPT-4 (session two). Each imaging study was presented with demographic data, the chief complaint, and associated symptoms, and diagnoses were registered using an online survey tool. The impact of Artificial Intelligence (AI) on diagnostic accuracy, confidence, user experience, input prompts, and generated responses was assessed. False information was registered. Linear mixed-effect models were used to quantify the factors (fixed: experience, modality, AI assistance; random: radiologist) influencing diagnostic accuracy and confidence. RESULTS When assessing if the correct diagnosis was among the top-3 differential diagnoses, diagnostic accuracy improved slightly from 181/240 (75.4%, unassisted) to 188/240 (78.3%, AI-assisted). Similar improvements were found when only the top differential diagnosis was considered. AI assistance was used in 77.5% of the readings. Three hundred nine prompts were generated, primarily involving differential diagnoses (59.1%) and imaging features of specific conditions (27.5%). Diagnostic confidence was significantly higher when readings were AI-assisted (p > 0.001). Twenty-three responses (7.4%) were classified as hallucinations, while two (0.6%) were misinterpretations. CONCLUSION Integrating GPT-4 in the diagnostic process improved diagnostic accuracy slightly and diagnostic confidence significantly. Potentially harmful hallucinations and misinterpretations call for caution and highlight the need for further safeguarding measures. CLINICAL RELEVANCE STATEMENT Using GPT-4 as a virtual assistant when reading images made six radiologists of different experience levels feel more confident and provide more accurate diagnoses; yet, GPT-4 gave factually incorrect and potentially harmful information in 7.4% of its responses.
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Affiliation(s)
- Robert Siepmann
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Marc Huppertz
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Annika Rastkhiz
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Matthias Reen
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Eric Corban
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Christian Schmidt
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Stephan Wilke
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Philipp Schad
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Can Yüksel
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Christiane Kuhl
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Daniel Truhn
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Sven Nebelung
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Aachen, Germany.
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Stanzione A, Lee KL, Sanmugalingam N, Rajendran I, Sushentsev N, Caglič I, Barrett T. Expect the unexpected: investigating discordant prostate MRI and biopsy results. Eur Radiol 2024:10.1007/s00330-024-10702-x. [PMID: 38503918 DOI: 10.1007/s00330-024-10702-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 02/08/2024] [Accepted: 02/24/2024] [Indexed: 03/21/2024]
Abstract
OBJECTIVES To evaluate discrepant radio-pathological outcomes in biopsy-naïve patients undergoing prostate MRI and to provide insights into the underlying causes. MATERIALS AND METHODS A retrospective analysis was conducted on 2780 biopsy-naïve patients undergoing prostate MRI at a tertiary referral centre between October 2015 and June 2022. Exclusion criteria were biopsy not performed, indeterminate MRI findings (PI-RADS 3), and clinically insignificant PCa (Gleason score 3 + 3). Patients with discrepant findings between MRI and biopsy results were categorised into two groups: MRI-negative/Biopsy-positive and MRI-positive/Biopsy-negative (biopsy-positive defined as Gleason score ≥ 3 + 4). An expert uroradiologist reviewed discrepant cases, retrospectively re-assigning PI-RADS scores, identifying any missed MRI targets, and evaluating the quality of MRI scans. Potential explanations for discrepancies included MRI overcalls (including known pitfalls), benign pathology findings, and biopsy targeting errors. RESULTS Patients who did not undergo biopsy (n = 1258) or who had indeterminate MRI findings (n = 204), as well as those with clinically insignificant PCa (n = 216), were excluded, with a total of 1102 patients analysed. Of these, 32/1,102 (3%) were classified as MRI-negative/biopsy-positive and 117/1102 (11%) as MRI-positive/biopsy-negative. In the MRI-negative/Biopsy-positive group, 44% of studies were considered non-diagnostic quality. Upon retrospective image review, target lesions were identified in 28% of cases. In the MRI-positive/Biopsy-negative group, 42% of cases were considered to be MRI overcalls, and 32% had an explanatory benign pathological finding, with biopsy targeting errors accounting for 11% of cases. CONCLUSION Prostate MRI demonstrated a high diagnostic accuracy, with low occurrences of discrepant findings as defined. Common reasons for MRI-positive/Biopsy-negative cases included explanatory benign findings and MRI overcalls. CLINICAL RELEVANCE STATEMENT This study highlights the importance of optimal prostate MRI image quality and expertise in reducing diagnostic errors, improving patient outcomes, and guiding appropriate management decisions in the prostate cancer diagnostic pathway. KEY POINTS • Discrepancies between prostate MRI and biopsy results can occur, with higher numbers of MRI-positive/biopsy-negative relative to MRI-negative/biopsy-positive cases. • MRI-positive/biopsy-negative cases were mostly overcalls or explainable by benign biopsy findings. • In about one-third of MRI-negative/biopsy-positive cases, a target lesion was retrospectively identified.
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Affiliation(s)
- Arnaldo Stanzione
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80131, Naples, Italy
- Department of Radiology, Addenbrooke's Hospital and University of Cambridge, Hills Road, Box 218, Cambridge, CB2 0QQ, UK
| | - Kang-Lung Lee
- Department of Radiology, Addenbrooke's Hospital and University of Cambridge, Hills Road, Box 218, Cambridge, CB2 0QQ, UK
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Nimalan Sanmugalingam
- Department of Radiology, Addenbrooke's Hospital and University of Cambridge, Hills Road, Box 218, Cambridge, CB2 0QQ, UK
| | - Ishwariya Rajendran
- Department of Radiology, Addenbrooke's Hospital and University of Cambridge, Hills Road, Box 218, Cambridge, CB2 0QQ, UK
| | - Nikita Sushentsev
- Department of Radiology, Addenbrooke's Hospital and University of Cambridge, Hills Road, Box 218, Cambridge, CB2 0QQ, UK
| | - Iztok Caglič
- Department of Radiology, Addenbrooke's Hospital and University of Cambridge, Hills Road, Box 218, Cambridge, CB2 0QQ, UK
| | - Tristan Barrett
- Department of Radiology, Addenbrooke's Hospital and University of Cambridge, Hills Road, Box 218, Cambridge, CB2 0QQ, UK.
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Topff L, Steltenpool S, Ranschaert ER, Ramanauskas N, Menezes R, Visser JJ, Beets-Tan RGH, Hartkamp NS. Artificial intelligence-assisted double reading of chest radiographs to detect clinically relevant missed findings: a two-centre evaluation. Eur Radiol 2024:10.1007/s00330-024-10676-w. [PMID: 38466390 DOI: 10.1007/s00330-024-10676-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 01/21/2024] [Accepted: 02/01/2024] [Indexed: 03/13/2024]
Abstract
OBJECTIVES To evaluate an artificial intelligence (AI)-assisted double reading system for detecting clinically relevant missed findings on routinely reported chest radiographs. METHODS A retrospective study was performed in two institutions, a secondary care hospital and tertiary referral oncology centre. Commercially available AI software performed a comparative analysis of chest radiographs and radiologists' authorised reports using a deep learning and natural language processing algorithm, respectively. The AI-detected discrepant findings between images and reports were assessed for clinical relevance by an external radiologist, as part of the commercial service provided by the AI vendor. The selected missed findings were subsequently returned to the institution's radiologist for final review. RESULTS In total, 25,104 chest radiographs of 21,039 patients (mean age 61.1 years ± 16.2 [SD]; 10,436 men) were included. The AI software detected discrepancies between imaging and reports in 21.1% (5289 of 25,104). After review by the external radiologist, 0.9% (47 of 5289) of cases were deemed to contain clinically relevant missed findings. The institution's radiologists confirmed 35 of 47 missed findings (74.5%) as clinically relevant (0.1% of all cases). Missed findings consisted of lung nodules (71.4%, 25 of 35), pneumothoraces (17.1%, 6 of 35) and consolidations (11.4%, 4 of 35). CONCLUSION The AI-assisted double reading system was able to identify missed findings on chest radiographs after report authorisation. The approach required an external radiologist to review the AI-detected discrepancies. The number of clinically relevant missed findings by radiologists was very low. CLINICAL RELEVANCE STATEMENT The AI-assisted double reader workflow was shown to detect diagnostic errors and could be applied as a quality assurance tool. Although clinically relevant missed findings were rare, there is potential impact given the common use of chest radiography. KEY POINTS • A commercially available double reading system supported by artificial intelligence was evaluated to detect reporting errors in chest radiographs (n=25,104) from two institutions. • Clinically relevant missed findings were found in 0.1% of chest radiographs and consisted of unreported lung nodules, pneumothoraces and consolidations. • Applying AI software as a secondary reader after report authorisation can assist in reducing diagnostic errors without interrupting the radiologist's reading workflow. However, the number of AI-detected discrepancies was considerable and required review by a radiologist to assess their relevance.
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Affiliation(s)
- Laurens Topff
- Department of Radiology, Netherlands Cancer Institute, Amsterdam, The Netherlands.
- GROW School for Oncology and Reproduction, Maastricht University, Maastricht, The Netherlands.
| | - Sanne Steltenpool
- Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Radiology, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - Erik R Ranschaert
- Department of Radiology, St. Nikolaus Hospital, Eupen, Belgium
- Ghent University, Ghent, Belgium
| | - Naglis Ramanauskas
- Oxipit UAB, Vilnius, Lithuania
- Department of Radiology, Nuclear Medicine and Medical Physics, Institute of Biomedical Sciences, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Renee Menezes
- Biostatistics Centre, Department of Psychosocial Research and Epidemiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Jacob J Visser
- Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Regina G H Beets-Tan
- Department of Radiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
- GROW School for Oncology and Reproduction, Maastricht University, Maastricht, The Netherlands
| | - Nolan S Hartkamp
- Department of Radiology, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
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Toxopeus R, Kasalak Ö, Yakar D, Noordzij W, Dierckx RAJO, Kwee TC. Is work overload associated with diagnostic errors on 18F-FDG-PET/CT? Eur J Nucl Med Mol Imaging 2024; 51:1079-1084. [PMID: 38030745 DOI: 10.1007/s00259-023-06543-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 11/22/2023] [Indexed: 12/01/2023]
Abstract
PURPOSE To determine the association between workload and diagnostic errors on 18F-FDG-PET/CT. MATERIALS AND METHODS This study included 103 18F-FDG-PET/CT scans with a diagnostic error that was corrected with an addendum between March 2018 and July 2023. All scans were performed at a tertiary care center. The workload of each nuclear medicine physician or radiologist who authorized the 18F-FDG-PET/CT report was determined on the day the diagnostic error was made and normalized for his or her own average daily production (workloadnormalized). A workloadnormalized of more than 100% indicates that the nuclear medicine physician or radiologist had a relative work overload, while a value of less than 100% indicates a relative work underload on the day the diagnostic error was made. The time of the day the diagnostic error was made was also recorded. Workloadnormalized was compared to 100% using a signed rank sum test, with the hypothesis that it would significantly exceed 100%. A Mann-Kendall test was performed to test the hypothesis that diagnostic errors would increase over the course of the day. RESULTS Workloadnormalized (median of 121%, interquartile range: 71 to 146%) on the days the diagnostic errors were made was significantly higher than 100% (P = 0.014). There was no significant upward trend in the frequency of diagnostic errors over the course of the day (Mann-Kendall tau = 0.05, P = 0.7294). CONCLUSION Work overload seems to be associated with diagnostic errors on 18F-FDG-PET/CT. Diagnostic errors were encountered throughout the entire working day, without any upward trend towards the end of the day.
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Affiliation(s)
- Romy Toxopeus
- Medical Imaging Center, Departments of Radiology and Nuclear Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Ömer Kasalak
- Medical Imaging Center, Departments of Radiology and Nuclear Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Derya Yakar
- Medical Imaging Center, Departments of Radiology and Nuclear Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Walter Noordzij
- Medical Imaging Center, Departments of Radiology and Nuclear Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Rudi A J O Dierckx
- Medical Imaging Center, Departments of Radiology and Nuclear Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Thomas C Kwee
- Medical Imaging Center, Departments of Radiology and Nuclear Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
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Ojeda Niño A, Nebreda Clavo CL, Batista Barreiros C, Vallejo Salamanca R. Glomus tumor causing chronic finger pain: ischemia test is a reliable clinical sign for the diagnosis. Case report and review of literature. Rev Esp Anestesiol Reanim (Engl Ed) 2024:S2341-1929(24)00043-X. [PMID: 38423461 DOI: 10.1016/j.redare.2024.02.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 12/12/2022] [Accepted: 01/11/2023] [Indexed: 03/02/2024]
Abstract
Glomus tumors are a rare, benign neoplasm arising from the neuroarterial structure known as the glomus body, which is a specialized arteriovenous shunt involved in temperature regulation. They account for less than 2% of soft tissue tumors and between 1% and 4.5% of tumors in the hand.. Despite their first descriptions appearing almost 100 years ago, late and missed diagnoses are common, leading to significant suffering. The classic diagnostic triad includes spontaneous pain, a sensation of pressure and tenderness, and cold hypersensitivity. Magnetic resonance imaging remains the most useful imaging modality. The abolition of pain after inflating a blood pressure cuff above the systolic blood pressure level (ischemia test) is highly diagnostic.Therefore, we suggest the routine use of this simple test in cases of upper limb pain of unclear etiology . Surgical excision is the treatment of choice and is curative.
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Affiliation(s)
- A Ojeda Niño
- Instituto Aliaga, Centro Médico Teknon, Barcelona, Spain; Department of Anesthesiology, Critical Care and Pain Medicine, Hospital Clínic de Barcelona, University of Barcelona, Spain.
| | | | - C Batista Barreiros
- Department of Anesthesiology, Critical Care and Pain Medicine, Hospital Clínic de Barcelona, University of Barcelona, Spain
| | - R Vallejo Salamanca
- Instituto Aliaga, Centro Médico Teknon, Barcelona, Spain; Psychology Department, Illinois Wesleyan University, Illinois, USA
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Mamede S, Zandbergen A, de Carvalho-Filho MA, Choi G, Goeijenbier M, van Ginkel J, Zwaan L, Paas F, Schmidt HG. Role of knowledge and reasoning processes as predictors of resident physicians' susceptibility to anchoring bias in diagnostic reasoning: a randomised controlled experiment. BMJ Qual Saf 2024:bmjqs-2023-016621. [PMID: 38365449 DOI: 10.1136/bmjqs-2023-016621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 01/26/2024] [Indexed: 02/18/2024]
Abstract
BACKGROUND Diagnostic errors have been attributed to reasoning flaws caused by cognitive biases. While experiments have shown bias to cause errors, physicians of similar expertise differed in susceptibility to bias. Resisting bias is often said to depend on engaging analytical reasoning, disregarding the influence of knowledge. We examined the role of knowledge and reasoning mode, indicated by diagnosis time and confidence, as predictors of susceptibility to anchoring bias. Anchoring bias occurs when physicians stick to an incorrect diagnosis triggered by early salient distracting features (SDF) despite subsequent conflicting information. METHODS Sixty-eight internal medicine residents from two Dutch university hospitals participated in a two-phase experiment. Phase 1: assessment of knowledge of discriminating features (ie, clinical findings that discriminate between lookalike diseases) for six diseases. Phase 2 (1 week later): diagnosis of six cases of these diseases. Each case had two versions differing exclusively in the presence/absence of SDF. Each participant diagnosed three cases with SDF (SDF+) and three without (SDF-). Participants were randomly allocated to case versions. Based on phase 1 assessment, participants were split into higher knowledge or lower knowledge groups. MAIN OUTCOME MEASUREMENTS frequency of diagnoses associated with SDF; time to diagnose; and confidence in diagnosis. RESULTS While both knowledge groups performed similarly on SDF- cases, higher knowledge physicians succumbed to anchoring bias less frequently than their lower knowledge counterparts on SDF+ cases (p=0.02). Overall, physicians spent more time (p<0.001) and had lower confidence (p=0.02) on SDF+ than SDF- cases (p<0.001). However, when diagnosing SDF+ cases, the groups did not differ in time (p=0.88) nor in confidence (p=0.96). CONCLUSIONS Physicians apparently adopted a more analytical reasoning approach when presented with distracting features, indicated by increased time and lower confidence, trying to combat bias. Yet, extended deliberation alone did not explain the observed performance differences between knowledge groups. Success in mitigating anchoring bias was primarily predicted by knowledge of discriminating features of diagnoses.
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Affiliation(s)
- Sílvia Mamede
- Institute of Medical Education Research Rotterdam, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Adrienne Zandbergen
- Department of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | - Goda Choi
- Department of Hematology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Marco Goeijenbier
- Department of Intensive Care, Spaarne Gasthuis, Haarlem, The Netherlands
- Department of Intensive Care, Erasmus MC, Rotterdam, The Netherlands
| | - Joost van Ginkel
- Department of Psychology, Methodology and Statistics, Leiden University, Leiden, The Netherlands
| | - Laura Zwaan
- Institute of Medical Education Research Rotterdam, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Fred Paas
- Department of Psychology, Education and Child Studies, Erasmus Universiteit Rotterdam, Rotterdam, The Netherlands
| | - Henk G Schmidt
- Department of Psychology, Education and Child Studies, Erasmus Universiteit Rotterdam, Rotterdam, The Netherlands
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Jeong CW, Han JH, Byun SS, Song C, Hong SH, Chung J, Seo SI, Ha HK, Hwang EC, Seo IY, Cheaib JG, Pierorazio PM, Han M, Kwak C. Rate of benign histology after resection of suspected renal cell carcinoma: multicenter comparison between Korea and the United States. BMC Cancer 2024; 24:216. [PMID: 38360715 PMCID: PMC10870474 DOI: 10.1186/s12885-024-11941-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 02/01/2024] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND In the United States, the rate of benign histology among resected renal tumors suspected to be malignant is increasing. We evaluated the rates in the Republic of Korea and assessed the racial effect using recent multi-institutional Korean-United States data. METHODS We conducted a multi-institutional retrospective study of 11,529 patients (8,812 from The Republic of Korea and 2,717 from the United States) and compared the rates of benign histology between the two countries. To evaluate the racial effect, we divided the patients into Korean, Asian in the US, and Non-Asian in the US. RESULTS The rates of benign histology and small renal masses in Korean patients were significantly lower than that in United States patients (6.3% vs. 14.3%, p < 0.001) and (≤ 4 cm, 7.6% vs. 19.5%, p < 0.001), respectively. Women, incidentaloma, partial nephrectomy, minimally invasive surgery, and recent surgery were associated with a higher rate of benign histology than others. CONCLUSIONS In Korea, the rate of benign histology among resected renal tumors was significantly lower than that in the United States. This disparity could be caused by environmental or cultural differences rather than racial differences. Our findings suggest that re-evaluating current context-specific standards of care is necessary to avoid overtreatment.
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Affiliation(s)
- Chang Wook Jeong
- Department of Urology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, 03080, Seoul, Korea
| | - Jang Hee Han
- Department of Urology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, 03080, Seoul, Korea
| | - Seok Soo Byun
- Department of Urology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Cheryn Song
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung-Hoo Hong
- Department of Urology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jinsoo Chung
- Department of Urology, National Cancer Center, Goyang, Korea
| | - Seong Il Seo
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hong Koo Ha
- Department of Urology, Pusan National University Hospital, Busan, Korea
| | - Eu Chang Hwang
- Department of Urology, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Ill Young Seo
- Department of Urology, Institute of Wonkwang Medical Science, Wonkwang University School of Medicine, Iksan, Korea
| | - Joseph G Cheaib
- Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Phillip M Pierorazio
- Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Urology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Misop Han
- Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Cheol Kwak
- Department of Urology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, 03080, Seoul, Korea.
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11
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Kaisey M, Solomon AJ. Multiple Sclerosis Diagnostic Delay and Misdiagnosis. Neurol Clin 2024; 42:1-13. [PMID: 37980109 DOI: 10.1016/j.ncl.2023.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2023]
Abstract
Multiple sclerosis (MS) misdiagnosis in the form of an incorrect diagnosis of MS, as well as delayed diagnosis in patients who do have MS, both influence patient clinical outcomes. Contemporary studies have reported data on factors associated with these diagnostic challenges and their frequency. Expediting diagnosis in patients with MS and reducing MS misdiagnosis in patients who do not have MS may be aided by educational efforts surrounding early MS symptoms and proper application of MS diagnostic criteria. Emerging novel MS diagnostic biomarkers may aid early and accurate diagnosis of MS in the future.
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Affiliation(s)
- Marwa Kaisey
- Department of Neurology, Cedars-Sinai Medical Center, 127 South San Vicente Boulevard, A6600, Los Angeles, CA 90048, USA.
| | - Andrew J Solomon
- Department of Neurological Sciences, University of Vermont, Larner College of Medicine, University Health Center, Arnold 2, 1 South Prospect Street, Burlington, VT 05401, USA
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12
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Frey J, Braun LT, Handgriff L, Kendziora B, Fischer MR, Reincke M, Zwaan L, Schmidmaier R. Insights into diagnostic errors in endocrinology: a prospective, case-based, international study. BMC Med Educ 2023; 23:934. [PMID: 38066602 PMCID: PMC10709946 DOI: 10.1186/s12909-023-04927-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 12/03/2023] [Indexed: 12/18/2023]
Abstract
BACKGROUND Diagnostic errors in internal medicine are common. While cognitive errors have previously been identified to be the most common contributor to errors, very little is known about errors in specific fields of internal medicine such as endocrinology. This prospective, multicenter study focused on better understanding the causes of diagnostic errors made by general practitioners and internal specialists in the area of endocrinology. METHODS From August 2019 until January 2020, 24 physicians completed five endocrine cases on an online platform that simulated the diagnostic process. After each case, the participants had to state and explain why they chose their assumed diagnosis. The data gathering process as well as the participants' explanations were quantitatively and qualitatively analyzed to determine the causes of the errors. The diagnostic processes in correctly and incorrectly solved cases were compared. RESULTS Seven different causes of diagnostic error were identified, the most frequent being misidentification (mistaking one diagnosis with a related one or with more frequent and similar diseases) in 23% of the cases. Other causes were faulty context generation (21%) and premature closure (17%). The diagnostic confidence did not differ between correctly and incorrectly solved cases (median 8 out of 10, p = 0.24). However, in incorrectly solved cases, physicians spent less time on the technical findings (such as lab results, imaging) (median 250 s versus 199 s, p < 0.049). CONCLUSIONS The causes for errors in endocrine case scenarios are similar to the causes in other fields of internal medicine. Spending more time on technical findings might prevent misdiagnoses in everyday clinical practice.
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Affiliation(s)
- Jessica Frey
- Medizinische Klinik und Poliklinik IV, University Hospital, Ludwig-Maximilians-University Munich, Ziemssenstr. 5, 80336, Munich, Germany
| | - Leah T Braun
- Medizinische Klinik und Poliklinik IV, University Hospital, Ludwig-Maximilians-University Munich, Ziemssenstr. 5, 80336, Munich, Germany.
| | - Laura Handgriff
- Medizinische Klinik und Poliklinik IV, University Hospital, Ludwig-Maximilians-University Munich, Ziemssenstr. 5, 80336, Munich, Germany
| | - Benjamin Kendziora
- Department of Dermatology and Allergology, University Hospital, LMU Munich, Munich, Germany
| | - Martin R Fischer
- Institute of Medical Education, University Hospital, LMU Munich, Munich, Germany
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, University Hospital, Ludwig-Maximilians-University Munich, Ziemssenstr. 5, 80336, Munich, Germany
| | - Laura Zwaan
- Erasmus MC iMERR (Institute of Medical Education Research Rotterdam), Rotterdam, Netherlands
| | - Ralf Schmidmaier
- Medizinische Klinik und Poliklinik IV, University Hospital, Ludwig-Maximilians-University Munich, Ziemssenstr. 5, 80336, Munich, Germany
- Institute of Medical Education, University Hospital, LMU Munich, Munich, Germany
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13
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Lisitano L, Röttinger T, Wiedl A, Rau K, Helling S, Cifuentes J, Jehs B, Härting M, Feitelson LM, Gleich J, Kiesl S, Pfeufer D, Neuerburg C, Mayr E, Förch S. Plain X-ray is insufficient for correct diagnosis of tibial shaft spiral fractures: a prospective trial. Eur J Trauma Emerg Surg 2023; 49:2339-2345. [PMID: 37269304 PMCID: PMC10728229 DOI: 10.1007/s00068-023-02285-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 05/20/2023] [Indexed: 06/05/2023]
Abstract
PURPOSE Tibial shaft spiral fractures and fractures of the distal third of the tibia (AO:42A/B/C and 43A) frequently occur with non-displaced posterior malleolus fractures (PM). This study investigated the hypothesis that plain X-ray is not sufficient for a reliable diagnosis of associated non-displaced PM fractures in tibial shaft spiral fractures. METHODS 50 X-rays showing 42A/B/C and 43A fractures were evaluated by two groups of physicians, each group was comprised of a resident and a fellowship-trained traumatologist or radiologist. Each group was tasked to make a diagnosis and/or suggest if further imaging was needed. One group was primed with the incidence of PM fractures and asked to explicitly assess the PM. RESULTS Overall, 9.13/25 (SD ± 5.77) PM fractures were diagnosed on X-ray. If the posterior malleolus fracture was named or a CT was requested, the fracture was considered "detected". With this in mind, 14.8 ± 5.95 posterior malleolus fractures were detected. Significantly more fractures were diagnosed/detected (14 vs. 4.25/25; p < 0.001/14.8 vs. 10.5/25; p < 0.001) in the group with awareness. However, there were significantly more false positives in the awareness group (2.5 vs. 0.5; p = 0.024). Senior physicians recognized slightly more fractures than residents (residents: 13.0 ± 7.79; senior physicians: 16.5 ± 3.70; p = 0.040). No significant differences were demonstrated between radiologists and trauma surgeons. The inner-rater reliability was high with 91.2% agreement. Inter-rater reliability showed fair agreement (Fleiss-Kappa 0.274, p < 0.001) across all examiners and moderate agreement (Fleiss-Kappa 0.561, p < 0.001) in group 2. CONCLUSION Only 17% of PM fractures were identified on plain X-ray and awareness of PM only improved diagnosis by 39%. While experiencing improved accuracy, CT imaging should be included in a comprehensive examination of tibial shaft spiral fractures. LEVEL OF EVIDENCE II. Diagnostic prospective cohort study. TRAIL REGISTRATION NUMBER DRKS00030075.
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Affiliation(s)
- Leonard Lisitano
- Department for Trauma, Orthopedics, Hand and Plastic Surgery, University Hospital Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany.
| | - Timon Röttinger
- Department for Trauma, Orthopedics, Hand and Plastic Surgery, University Hospital Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany
| | - Andreas Wiedl
- Department for Trauma, Orthopedics, Hand and Plastic Surgery, University Hospital Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany
| | - Kim Rau
- Department for Trauma, Orthopedics, Hand and Plastic Surgery, University Hospital Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany
| | - Sönke Helling
- Department for Trauma, Orthopedics, Hand and Plastic Surgery, University Hospital Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany
| | - Jairo Cifuentes
- Department for Trauma, Orthopedics, Hand and Plastic Surgery, University Hospital Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany
| | - Bertram Jehs
- Department for Diagnostic and Interventional Radiology, University Hospital Augsburg, Augsburg, Germany
| | - Mark Härting
- Department for Diagnostic and Interventional Radiology, University Hospital Augsburg, Augsburg, Germany
| | - Laura-Marie Feitelson
- Department for Diagnostic and Interventional Radiology, University Hospital Augsburg, Augsburg, Germany
| | - Johannes Gleich
- Department for Orthopedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital LMU Munich, Munich, Germany
| | - Sophia Kiesl
- Department of Radiology, University Hospital LMU Munich, Munich, Germany
| | - Daniel Pfeufer
- Department for Orthopedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital LMU Munich, Munich, Germany
| | - Carl Neuerburg
- Department for Orthopedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital LMU Munich, Munich, Germany
| | - Edgar Mayr
- Department for Trauma, Orthopedics, Hand and Plastic Surgery, University Hospital Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany
| | - Stefan Förch
- Department for Trauma, Orthopedics, Hand and Plastic Surgery, University Hospital Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany
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14
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Payne R, Clarke A, Swann N, van Dael J, Brenman N, Rosen R, Mackridge A, Moore L, Kalin A, Ladds E, Hemmings N, Rybczynska-Bunt S, Faulkner S, Hanson I, Spitters S, Wieringa S, Dakin FH, Shaw SE, Wherton J, Byng R, Husain L, Greenhalgh T. Patient safety in remote primary care encounters: multimethod qualitative study combining Safety I and Safety II analysis. BMJ Qual Saf 2023:bmjqs-2023-016674. [PMID: 38050161 DOI: 10.1136/bmjqs-2023-016674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 10/31/2023] [Indexed: 12/06/2023]
Abstract
BACKGROUND Triage and clinical consultations increasingly occur remotely. We aimed to learn why safety incidents occur in remote encounters and how to prevent them. SETTING AND SAMPLE UK primary care. 95 safety incidents (complaints, settled indemnity claims and reports) involving remote interactions. Separately, 12 general practices followed 2021-2023. METHODS Multimethod qualitative study. We explored causes of real safety incidents retrospectively ('Safety I' analysis). In a prospective longitudinal study, we used interviews and ethnographic observation to produce individual, organisational and system-level explanations for why safety and near-miss incidents (rarely) occurred and why they did not occur more often ('Safety II' analysis). Data were analysed thematically. An interpretive synthesis of why safety incidents occur, and why they do not occur more often, was refined following member checking with safety experts and lived experience experts. RESULTS Safety incidents were characterised by inappropriate modality, poor rapport building, inadequate information gathering, limited clinical assessment, inappropriate pathway (eg, wrong algorithm) and inadequate attention to social circumstances. These resulted in missed, inaccurate or delayed diagnoses, underestimation of severity or urgency, delayed referral, incorrect or delayed treatment, poor safety netting and inadequate follow-up. Patients with complex pre-existing conditions, cardiac or abdominal emergencies, vague or generalised symptoms, safeguarding issues, failure to respond to previous treatment or difficulty communicating seemed especially vulnerable. General practices were facing resource constraints, understaffing and high demand. Triage and care pathways were complex, hard to navigate and involved multiple staff. In this context, patient safety often depended on individual staff taking initiative, speaking up or personalising solutions. CONCLUSION While safety incidents are extremely rare in remote primary care, deaths and serious harms have resulted. We offer suggestions for patient, staff and system-level mitigations.
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Affiliation(s)
- Rebecca Payne
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Aileen Clarke
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Nadia Swann
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Jackie van Dael
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Natassia Brenman
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | | | - Lucy Moore
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Asli Kalin
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Emma Ladds
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | | | - Stuart Faulkner
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Isabel Hanson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sophie Spitters
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Sietse Wieringa
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Sustainable Health Unit, University of Oslo, Oslo, Norway
| | - Francesca H Dakin
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sara E Shaw
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Joseph Wherton
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Richard Byng
- Peninsula Schools of Medicine and Dentistry, University of Plymouth, Plymouth, UK
| | - Laiba Husain
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Trisha Greenhalgh
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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15
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Introzzi L, Zonca J, Cabitza F, Cherubini P, Reverberi C. Enhancing human-AI collaboration: The case of colonoscopy. Dig Liver Dis 2023:S1590-8658(23)01007-1. [PMID: 37940501 DOI: 10.1016/j.dld.2023.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 10/19/2023] [Accepted: 10/23/2023] [Indexed: 11/10/2023]
Abstract
Diagnostic errors impact patient health and healthcare costs. Artificial Intelligence (AI) shows promise in mitigating this burden by supporting Medical Doctors in decision-making. However, the mere display of excellent or even superhuman performance by AI in specific tasks does not guarantee a positive impact on medical practice. Effective AI assistance should target the primary causes of human errors and foster effective collaborative decision-making with human experts who remain the ultimate decision-makers. In this narrative review, we apply these principles to the specific scenario of AI assistance during colonoscopy. By unraveling the neurocognitive foundations of the colonoscopy procedure, we identify multiple bottlenecks in perception, attention, and decision-making that contribute to diagnostic errors, shedding light on potential interventions to mitigate them. Furthermore, we explored how existing AI devices fare in clinical practice and whether they achieved an optimal integration with the human decision-maker. We argue that to foster optimal Human-AI collaboration, future research should expand our knowledge of factors influencing AI's impact, establish evidence-based cognitive models, and develop training programs based on them. These efforts will enhance human-AI collaboration, ultimately improving diagnostic accuracy and patient outcomes. The principles illuminated in this review hold more general value, extending their relevance to a wide array of medical procedures and beyond.
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Affiliation(s)
- Luca Introzzi
- Department of Psychology, Università Milano - Bicocca, Milano, Italy
| | - Joshua Zonca
- Department of Psychology, Università Milano - Bicocca, Milano, Italy; Milan Center for Neuroscience, Università Milano - Bicocca, Milano, Italy
| | - Federico Cabitza
- Department of Informatics, Systems and Communication, Università Milano - Bicocca, Milano, Italy; IRCCS Istituto Ortopedico Galeazzi, Milano, Italy
| | - Paolo Cherubini
- Department of Brain and Behavioral Sciences, Università Statale di Pavia, Pavia, Italy
| | - Carlo Reverberi
- Department of Psychology, Università Milano - Bicocca, Milano, Italy; Milan Center for Neuroscience, Università Milano - Bicocca, Milano, Italy.
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16
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Herasevich S, Soleimani J, Huang C, Pinevich Y, Dong Y, Pickering BW, Murad MH, Barwise AK. Diagnostic error among vulnerable populations presenting to the emergency department with cardiovascular and cerebrovascular or neurological symptoms: a systematic review. BMJ Qual Saf 2023; 32:676-688. [PMID: 36972982 DOI: 10.1136/bmjqs-2022-015038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 03/10/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND Diagnostic error (DE) is a common problem in clinical practice, particularly in the emergency department (ED) setting. Among ED patients presenting with cardiovascular or cerebrovascular/neurological symptoms, a delay in diagnosis or failure to hospitalise may be most impactful in terms of adverse outcomes. Minorities and other vulnerable populations may be at higher risk of DE. We aimed to systematically review studies reporting the frequency and causes of DE in under-resourced patients presenting to the ED with cardiovascular or cerebrovascular/neurological symptoms. METHODS We searched EBM Reviews, Embase, Medline, Scopus and Web of Science from 2000 through 14 August 2022. Data were abstracted by two independent reviewers using a standardised form. The risk of bias (ROB) was assessed using the Newcastle-Ottawa Scale, and the certainty of evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation approach. RESULTS Of the 7342 studies screened, we included 20 studies evaluating 7436,737 patients. Most studies were conducted in the USA, and one study was multicountry. 11 studies evaluated DE in patients with cerebrovascular/neurological symptoms, 8 studies with cardiovascular symptoms and 1 study examined both types of symptoms. 13 studies investigated missed diagnoses and 7 studies explored delayed diagnoses. There was significant clinical and methodological variability, including heterogeneity of DE definitions and predictor variable definitions as well as methods of DE assessment, study design and reporting.Among the studies evaluating cardiovascular symptoms, black race was significantly associated with higher odds of DE in 4/6 studies evaluating missed acute myocardial infarction (AMI)/acute coronary syndrome (ACS) diagnosis compared with white race (OR from 1.18 (1.12-1.24) to 4.5 (1.8-11.8)). The association between other analysed factors (ethnicity, insurance and limited English proficiency) and DE in this domain varied from study to study and was inconclusive.Among the studies evaluating DE in patients with cerebrovascular/neurological symptoms, no consistent association was found indicating higher or lower odds of DE. Although some studies showed significant differences, these were not consistently in the same direction.The overall ROB was low for most included studies; however, the certainty of evidence was very low, mostly due to serious inconsistency in definitions and measurement approaches across studies. CONCLUSIONS This systematic review demonstrated consistent increased odds of missed AMI/ACS diagnosis among black patients presenting to the ED compared with white patients in most studies. No consistent associations between demographic groups and DE related to cerebrovascular/neurological diagnoses were identified. More standardised approaches to study design, measurement of DE and outcomes assessment are needed to understand this problem among vulnerable populations. TRIAL REGISTRATION NUMBER The study protocol was registered in the International Prospective Register of Systematic Reviews PROSPERO 2020 CRD42020178885 and is available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020178885.
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Affiliation(s)
- Svetlana Herasevich
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jalal Soleimani
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Chanyan Huang
- Department of Anaesthesiology, Sun Yat-sen University First Affiliated Hospital, Guangzhou, Guangdong, China
| | - Yuliya Pinevich
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Yue Dong
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Brian W Pickering
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Mohammad H Murad
- Center for Science of Healthcare Delivery, Division of Preventive Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Amelia K Barwise
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Bioethics Research Program, Mayo Clinic, Rochester, MN, USA
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17
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Littmann L. Common ECG interpretation software mistakes. Part I: False reporting of myocardial infarction. J Electrocardiol 2023; 81:32-35. [PMID: 37517198 DOI: 10.1016/j.jelectrocard.2023.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 07/05/2023] [Accepted: 07/21/2023] [Indexed: 08/01/2023]
Abstract
The purpose of computerized analysis of electrocardiograms (ECGs) is to provide rapid interpretation in places where ECG experts are not available, and to save physician time for all providers. For the most part, contemporary interpretation algorithms perform remarkably well and offer correct diagnoses of common ECG abnormalities. Diagnostic accuracy for myocardial ischemia and infarction is reasonably good but with these conditions, false positive and false negative readings can be disastrous. It is essential, therefore, that computerized statements be over-read by trained physicians. A three-part mini-series is intended to provide assistance to quickly recognize and correct common interpretation software mistakes. This first chapter presents interpretation errors that falsely indicate myocardial infarction.
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Affiliation(s)
- Laszlo Littmann
- Department of Internal Medicine, Atrium Health Carolinas Medical Center, Charlotte, NC, USA.
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18
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Littmann L. Common ECG interpretation software mistakes Part II: Computer errors that hide diagnostic clues. J Electrocardiol 2023; 81:277-280. [PMID: 37633808 DOI: 10.1016/j.jelectrocard.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 07/22/2023] [Accepted: 08/04/2023] [Indexed: 08/28/2023]
Abstract
Electrocardiogram (ECG) interpretation software mistakes can lead to incorrect diagnoses and inappropriate treatments. Occasionally, however, repetitive and consistent computer errors may hide important clues for correct diagnoses that otherwise could have been missed. We present a collection of a few common and clinically important such peculiarities, and provide tools on how to prove or disprove the suspected diagnosis. In addition to the illustrations in print, an online supplement (OS) shows more examples of the discussed phenomena. In each ECG, the original computer interpretations were enlarged for legibility.
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Affiliation(s)
- Laszlo Littmann
- Department of Internal Medicine, Atrium Health Carolinas Medical Center, Charlotte, NC, USA.
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19
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Littmann L. Common ECG interpretation software mistakes Part III: Computer errors that should never be missed. J Electrocardiol 2023; 81:281-284. [PMID: 37599144 DOI: 10.1016/j.jelectrocard.2023.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 08/07/2023] [Accepted: 08/08/2023] [Indexed: 08/22/2023]
Abstract
Electrocardiogram interpretation software mistakes can lead to incorrect diagnoses and inappropriate treatments. Occasionally, the consequences of not recognizing such mistakes are disastrous. This final chapter on software mistakes describes three relatively common computer errors that should never be missed because not recognizing them can result in stroke, cardiac arrest, and even death. In each of the scenarios covered, we describe the clinical background, and provide simple recommendations on how such mistakes can be easily identified and corrected.
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Affiliation(s)
- Laszlo Littmann
- Department of Internal Medicine, Atrium Health Carolinas Medical Center, P. O. Box 32861, Charlotte, NC 28232, USA.
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20
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Connor DM, Dhaliwal G. Moving upstream to address diagnostic disparities. BMJ Qual Saf 2023; 32:620-622. [PMID: 37414556 DOI: 10.1136/bmjqs-2023-016130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/16/2023] [Indexed: 07/08/2023]
Affiliation(s)
- Denise M Connor
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
- Medical Service, San Francisco VA Medical Center, San Francisco, California, USA
| | - Gurpreet Dhaliwal
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
- Medical Service, San Francisco VA Medical Center, San Francisco, California, USA
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Wenger DE, Tibbo ME, Hadley ML, Sierra RJ, Welch TJ. Osteoid osteomas of the hip: a well-recognized entity with a proclivity for misdiagnosis. Eur Radiol 2023; 33:8343-8352. [PMID: 37284866 PMCID: PMC10598167 DOI: 10.1007/s00330-023-09765-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 02/27/2023] [Accepted: 03/10/2023] [Indexed: 06/08/2023]
Abstract
OBJECTIVES The diagnosis of osteoid osteomas (OO) about the hip can be challenging as presenting symptoms can mimic other, more common, periarticular pathologies. Our aims were to identify the most common misdiagnoses and treatments, mean delay in diagnosis, characteristic imaging features and provide tips for avoiding diagnostic imaging pitfalls for patients with OO of the hip. METHODS We identified 33 patients (34 tumors) with OO about the hip who were referred for radiofrequency ablation between 1998 and 2020. Imaging studies reviewed included radiographs (n = 29), CT (n = 34), and MRI (n = 26). RESULTS The most common initial diagnoses were femoral neck stress fracture (n = 8), femoroacetabular impingement (FAI) (n = 7), and malignant tumor or infection (n = 4). The mean time from symptom onset to diagnosis of OO was 15 months (range, 0.4-84). The mean time from initial incorrect diagnosis to OO diagnosis was 9 months (range, 0-46). CONCLUSIONS The diagnosis of OO of the hip is challenging, with up to 70% of cases initially misdiagnosed as a femoral neck stress fracture, FAI, bone tumor, or other joint pathology in our series. Consideration of OO in the differential diagnosis of hip pain in adolescent patients and awareness of the characteristic imaging findings are critical for making an accurate diagnosis. KEY POINTS • The diagnosis of osteoid osteoma of the hip can be challenging, as demonstrated by long delays in time to initial diagnosis and high rates of misdiagnoses which can lead to inappropriate interventions. • Familiarity with the spectrum of imaging features of OO, especially on MRI, is imperative given the increase in the utilization of this modality for the evaluation of young patients with hip pain and FAI. • Consideration of OO in the differential diagnosis of hip pain in adolescent patients and awareness of the characteristic imaging findings, including bone marrow edema and the utility of CT, are critical for making a timely and accurate diagnosis.
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Affiliation(s)
- Doris E Wenger
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, USA.
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, USA.
| | - Meagan E Tibbo
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
| | - Matthew L Hadley
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
| | - Rafael J Sierra
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
| | - Timothy J Welch
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
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22
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Sébastien P, Jacques D, Catherine P, Xavier G. Diagnosis and treatment of "chronic Lyme": primum non nocere. BMC Infect Dis 2023; 23:642. [PMID: 37784031 PMCID: PMC10544220 DOI: 10.1186/s12879-023-08618-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 09/18/2023] [Indexed: 10/04/2023] Open
Abstract
BACKGROUND Approximately 10% of patients experience prolonged symptoms after Lyme disease. PTLDS (post treatment Lyme disease syndrome) is a controversial topic. It has been described as a source of overdiagnosis and off-label treatment. This review aims to describe the diagnostic errors and adverse events associated with the diagnosis and treatment of PTLDS. METHODS systematic review of the literature in the Medline and Cochrane Library databases, according to PRISMA criteria, including randomized clinical trials (RCT), observational studies, and case reports addressing diagnostic errors and adverse events published between January 2010 and November 2020 in English or French. Selection used a quadruple reading process on the basis of the titles and abstracts of the different articles, followed by a full reading. RESULTS 17 studies were included: 1 RCT, 6 observational studies and 10 case reports. In the 6 observational studies, overdiagnosis rates were very high, ranging from 80 to 100%. The new diagnoses were often psychiatric, rheumatological and neurological. Disorders with somatic symptoms were often cited. Diagnostic delays were identified for cancers and frontoparietal dementia. In the RCT and observational studies, prolonged anti-infective treatments were also responsible for adverse events, with emergency room visits and/or hospitalization. The most common adverse events were diarrhea, sometimes with Clostridium difficile colitis, electrolyte abnormalities, sepsis, bacterial and fungal infections, and anaphylactic reactions. CONCLUSION This review highlights the risks of prolonged anti-infective treatments that have not been proven to be beneficial in PTLDS. It emphasizes the ethical imperative of the "primum non nocere" principle, which underscores the importance of not causing harm to patients. Physicians should exercise caution in diagnosing PTLDS and consider the potential risks associated with off-label treatments.
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Affiliation(s)
| | | | - Plotton Catherine
- Campus Santé Innovations, SAINT-PRIEST-EN-JAREZ, Jean-Monnet University, 10 RUE de la Marandière, 42270, Saint-Étienne, France
| | - Gocko Xavier
- Campus Santé Innovations, SAINT-PRIEST-EN-JAREZ, Jean-Monnet University, 10 RUE de la Marandière, 42270, Saint-Étienne, France.
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23
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Sung Y, Hong SB. Diagnostic Hierarchy of Tic Disorders in Real-World Clinical Practice. Soa Chongsonyon Chongsin Uihak 2023; 34:236-241. [PMID: 37841482 PMCID: PMC10568186 DOI: 10.5765/jkacap.230034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 07/04/2023] [Accepted: 07/21/2023] [Indexed: 10/17/2023] Open
Abstract
Objectives According to the 10th revision of the International Classification of Diseases, the main categories of tic disorders (F95.0, F95.1, and F95.2) follow a diagnostic hierarchy based on the duration and diversity of tic symptoms. The present study investigated the use of this diagnostic hierarchy in real-world clinical practice. Methods Based on the National Health Insurance Service-National Health Information Database, the diagnosis of transient tic disorder (F95.0) made after a diagnosis of chronic motor or vocal tic disorder (F95.1) or Tourette's syndrome (F95.2) and diagnosis of chronic motor or vocal tic disorder (F95.1) made after a diagnosis of Tourette's syndrome (F95.2) were referred to as type A errors. The diagnosis of transient tic disorder (F95.0) repeated after a period of >12 months was referred to as type B error. Demographic and clinical differences according to the diagnostic error types were analyzed using analysis of variance, Student's t-tests, and chi-squared tests. Results Most participants (96.5%) were without errors in the diagnosis of tic disorders. Higher proportions of males (p=0.005) and antipsychotic prescriptions (p<0.001) were observed in patients with type A or B diagnostic errors. A higher proportion of health insurance holders was observed among those with type A errors (p=0.027). Conclusion Errors were absent in majority of the tic diagnoses in real-world clinical practice in terms of the diagnostic hierarchy.
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Affiliation(s)
- Yeeji Sung
- Department of Psychiatry, Seoul National University Hospital, Seoul, Korea
- Department of Psychiatry, Seoul National University College of Medicine, Seoul, Korea
| | - Soon-Beom Hong
- Department of Psychiatry, Seoul National University Hospital, Seoul, Korea
- Department of Psychiatry, Seoul National University College of Medicine, Seoul, Korea
- Institute of Human Behavioral Medicine, Seoul National University Medical Research Center, Seoul, Korea
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Kasalak Ö, Pennings JP, den Akker JWO, Yakar D, Kwee TC. Why don't we inform patients about the risk of diagnostic errors? Eur J Radiol 2023; 165:110956. [PMID: 37418799 DOI: 10.1016/j.ejrad.2023.110956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 06/23/2023] [Accepted: 07/02/2023] [Indexed: 07/09/2023]
Abstract
The principles of autonomy and informed consent dictate that patients who undergo a radiological examination should actually be informed about the risk of diagnostic errors. Implementing such a policy could potentially increase the quality of care. However, due to the vast number of radiological examinations that are performed in each hospital each day, financial constraints, and the risk of losing trust, patients, and income if the requirement for informed consent is not imposed by law on a state or national level, it may be challenging to inform patients about the risk of diagnostic errors. Future research is necessary to determine if and how an informed consent procedure for diagnostic errors can be implemented in clinical practice.
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Affiliation(s)
- Ömer Kasalak
- Medical Imaging Center, Department of Radiology, University Medical Center Groningen, University of Groningen, The Netherlands.
| | - Jan P Pennings
- Medical Imaging Center, Department of Radiology, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Jeroen W Op den Akker
- Medical Imaging Center, Department of Radiology, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Derya Yakar
- Medical Imaging Center, Department of Radiology, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Thomas C Kwee
- Medical Imaging Center, Department of Radiology, University Medical Center Groningen, University of Groningen, The Netherlands
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25
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Shah ZA, Fatima K, Hamid H, Ilyas M, Nouman M, Zeb M. Acute pancreatitis with chylous ascites mimicking acute appendicitis: A rare case report. Int J Surg Case Rep 2023; 108:108462. [PMID: 37423146 PMCID: PMC10382834 DOI: 10.1016/j.ijscr.2023.108462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 06/20/2023] [Accepted: 06/27/2023] [Indexed: 07/11/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE Chylous ascites, characterized by the accumulation of lymphatic fluid in the peritoneal cavity, presents a significant diagnostic and management challenge, particularly in resource-limited settings. CASE PRESENTATION We report a case of a 63-year-old female with acute abdominal pain who was initially diagnosed with acute perforated appendicitis. During open surgery, Chylous ascites was found with normal appendix and bulky pancrease with surrounding fluid accumulation. Drain was placed in lesser sac area and appendectomy was performed with drain placed in right iliac fossa. Recovery was uneventful. CLINICAL DISCUSSION Chylous ascites can be challenging to diagnose, especially in resource-limited settings. Laboratory analysis and imaging studies play a critical role in establishing the diagnosis, while conservative measures and invasive interventions, if necessary, comprise the treatment strategy. CONCLUSION Our case highlights the importance of considering chylous ascites as a potential differential diagnosis in acute abdomen cases. Accurate diagnosis and management can be particularly challenging in resource-limited settings, and increased awareness among clinicians and further research is necessary to improve outcomes for patients.
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Affiliation(s)
| | | | | | | | | | - Muhammad Zeb
- General Surgery Department, Hayatabad Medical Complex, Peshawar, Pakistan.
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26
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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 Med Educ 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] [What about the content of this article? (0)] [Affiliation(s)] [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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Binmadi NO, Alhindi AA, Alsharif MT, Jamal BT, Mair YH. The value of a specialized second-opinion pathological diagnosis for oral and maxillofacial lesions. BMC Oral Health 2023; 23:378. [PMID: 37296405 PMCID: PMC10257276 DOI: 10.1186/s12903-023-03085-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Accepted: 05/27/2023] [Indexed: 06/12/2023] Open
Abstract
OBJECTIVES An error in the diagnosis of an oral or maxillofacial lesion could potentially be detrimental to a patient's prognosis and management. Major discrepancies between the initial and subsequent diagnoses of head and neck pathologies range from 7 to 53%. This study determined the rate of discrepancies found in the diagnoses of oral and maxillofacial lesions after a second opinion in Saudi Arabia. METHODS A retrospective single-center study was conducted by oral and maxillofacial pathology consultants to review all cases referred for a second opinion to the oral and maxillofacial pathology laboratory between January 2015 and December 2020. If the second-opinion diagnosis matched the original diagnosis, this was described as "agreement." If the second-opinion diagnosis did not match the original diagnosis but would not change the management or prognosis of a patient, this was classified as a "minor disagreement." If the second-opinion diagnosis resulted in the changing of a patient's management or prognosis, this was categorized as a "major disagreement." Chi-square test and Fisher's exact test were used to compare data between original and second-opinion diagnoses. A p-value of less than 0.05 was considered significant. RESULTS Of 138 cases, 59 (43%) had an initial diagnosis and a second-opinion diagnosis that were in major disagreement. The most common tumor for which there was a major disagreement was squamous cell carcinoma. No single factor influenced the occurrence of major disagreements. CONCLUSIONS Our evaluation reiterates the importance of obtaining a second opinion from a specialist in oral and maxillofacial pathology to improve the diagnostic accuracy for lesions. A formal system for this step, in addition to the obtaining of adequate clinical and radiographic information about a patient, is mandatory for the review of difficult cases.
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Affiliation(s)
- Nada O Binmadi
- Department of Oral Diagnostic Sciences, King Abdulaziz University Faculty of Dentistry, P.O. Box 80209, Jeddah, 21589, Saudi Arabia.
| | - Areej A Alhindi
- Department of Oral Diagnostic Sciences, King Abdulaziz University Faculty of Dentistry, P.O. Box 80209, Jeddah, 21589, Saudi Arabia
| | - Maha T Alsharif
- Department of Oral Diagnostic Sciences, King Abdulaziz University Faculty of Dentistry, P.O. Box 80209, Jeddah, 21589, Saudi Arabia
| | - Basem T Jamal
- Department of Oral and Maxillofacial Surgery, King Abdulaziz University Faculty of Dentistry, Jeddah, Saudi Arabia
| | - Yasmin H Mair
- Department of Oral Diagnostic Sciences, King Abdulaziz University Faculty of Dentistry, P.O. Box 80209, Jeddah, 21589, Saudi Arabia
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Ihrler S, Agaimy A, Guntinas-Lichius O, Haas C, Greber L. [Why is the histomorphological diagnosis of small salivary gland tumours so much more difficult?]. Pathologie (Heidelb) 2023:10.1007/s00292-023-01196-3. [PMID: 37261494 DOI: 10.1007/s00292-023-01196-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Accepted: 11/08/2022] [Indexed: 06/02/2023]
Abstract
There is a widespread impression among clinicians and pathologists that the histomorphological diagnosis of minor salivary gland tumours is more difficult and more frequently misdiagnosed than that of major glands. This is based on subjective clinical impression; scientific proof of and potential reasons for this difference are lacking. We identified 14 putative clinical, histopathological and combined clinical-histological reasons and four consequences, which together could explain the perceived greater difficulty of diagnosing minor gland tumours. We performed a thorough literature search and a statistical comparison of data from a personal large consultation series (biased for "difficult" cases) with cumulated data from a routine, unselected (non-consultation) series from the literature. Through this comparison, we could prove with statistical significance a series of reasons and consequences for this greater diagnostic difficulty in minor glands. Frequent incisional biopsies, almost obligatory low-grade bland cytology in malignant tumours and insufficient clinical-pathological communication emerged as the most important reasons. The special anatomic location of the hard palate contributes to further diagnostic difficulties, such as tumour necrosis, mucosal ulceration, pseudoinvasion and the "tumoural-mucosal fusion" phenomenon. Knowledge of these pitfalls in clinic and pathology can help overcome these difficulties and reduce the misdiagnosis rate in minor gland tumours. Our findings result in a series of recommendations both for the clinic and pathology.
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Affiliation(s)
- Stephan Ihrler
- DERMPATH München, Bayerstr. 69, 80335, München, Deutschland.
- Pathologisches Institut, Ludwig-Maximilians-Universität, München, Deutschland.
| | - Abbas Agaimy
- Institut für Pathologie, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Deutschland
| | | | - Christian Haas
- DERMPATH München, Bayerstr. 69, 80335, München, Deutschland
| | - Lukas Greber
- Medizinische Fakultät, Zahnmedizin, Ludwig-Maximilians-Universität, München, Deutschland
- Sanitätsunterstützungszentrum München, Bundeswehr, München, Deutschland
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29
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Côté-Corriveau G, Luu TM, Lewin A, Brousseau É, Ayoub A, Blaser C, Auger N. Hospitalization for child maltreatment and other types of injury during the COVID-19 pandemic. Child Abuse Negl 2023; 140:106186. [PMID: 37060690 PMCID: PMC10080276 DOI: 10.1016/j.chiabu.2023.106186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 03/13/2023] [Accepted: 03/31/2023] [Indexed: 05/06/2023]
Abstract
BACKGROUND The possibility that child maltreatment was misclassified as unintentional injury during the COVID-19 pandemic has not been evaluated. OBJECTIVE We assessed if child maltreatment hospitalizations changed during the pandemic, and if the change was accompanied by an increase in unintentional injuries. PARTICIPANTS AND SETTING This study included children aged 0-4 years who were admitted for maltreatment or unintentional injuries between April 2006 and March 2021 in hospitals of Quebec, Canada. METHODS We used interrupted time series regression to estimate the effect of the pandemic on hospitalization rates for maltreatment, compared with unintentional transport accidents, falls, and mechanical force injuries. We assessed if the change in maltreatment hospitalization was accompanied by an increase in specific types of unintentional injury. RESULTS Hospitalizations for child maltreatment decreased from 16.3 per 100,000 (95 % CI 9.1-23.4) the year before the pandemic to 13.2 per 100,000 (95 % CI 6.7-19.7) during the first lockdown. Hospitalizations for most types of unintentional injury also decreased, but injuries due to falls involving another person increased from 9.0 to 16.5 per 100,000. Hospitalization rates for maltreatment and unintentional injury remained low during the second lockdown, but mechanical force injuries involving another person increased from 3.8 to 8.1 per 100,000. CONCLUSIONS Hospitalizations for child maltreatment may have been misclassified as unintentional injuries involving another person during the pandemic. Children admitted for these types of unintentional injuries may benefit from closer assessment to rule out maltreatment.
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Affiliation(s)
- Gabriel Côté-Corriveau
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada; Institut national de santé publique du Québec, Montreal, Quebec, Canada; Department of Pediatrics, Sainte-Justine Hospital Research Centre, University of Montreal, Montreal, Quebec, Canada; University of Montreal Hospital Research Centre, Montreal, Quebec, Canada
| | - Thuy Mai Luu
- Department of Pediatrics, Sainte-Justine Hospital Research Centre, University of Montreal, Montreal, Quebec, Canada
| | - Antoine Lewin
- Medical Affairs and Innovation, Hema-Quebec, Saint-Laurent, Quebec, Canada; Department of Obstetrics and Gynecology, University of Sherbrooke, Sherbrooke, Quebec, Canada
| | - Émilie Brousseau
- Institut national de santé publique du Québec, Montreal, Quebec, Canada; University of Montreal Hospital Research Centre, Montreal, Quebec, Canada
| | - Aimina Ayoub
- Institut national de santé publique du Québec, Montreal, Quebec, Canada; University of Montreal Hospital Research Centre, Montreal, Quebec, Canada
| | - Christine Blaser
- Department of Social and Preventive Medicine, School of Public Health, University of Montreal, Montreal, Quebec, Canada
| | - Nathalie Auger
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada; Institut national de santé publique du Québec, Montreal, Quebec, Canada; University of Montreal Hospital Research Centre, Montreal, Quebec, Canada; Department of Social and Preventive Medicine, School of Public Health, University of Montreal, Montreal, Quebec, Canada.
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30
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Wiegand AA, Sheikh T, Zannath F, Trudeau NM, Dukhanin V, McDonald KM. "It's probably an STI because you're gay": a qualitative study of diagnostic error experiences in sexual and gender minority individuals. BMJ Qual Saf 2023:bmjqs-2022-015629. [PMID: 37164638 DOI: 10.1136/bmjqs-2022-015629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 04/24/2023] [Indexed: 05/12/2023]
Abstract
BACKGROUND There is a critical need to identify specific causes of and tailored solutions to diagnostic error in sexual and gender minority (SGM) populations. PURPOSE To identify challenges to diagnosis in SGM adults, understand the impacts of patient-reported diagnostic errors on patients' lives and elicit solutions. METHODS Qualitative study using in-depth semistructured interviews. Participants were recruited using convenience and snowball sampling. Recruitment efforts targeted 22 SGM-focused organisations, academic centres and clinics across the USA. Participants were encouraged to share study details with personal contacts. Interviews were analysed using codebook thematic analysis. RESULTS Interviewees (n=20) ranged from 20 to 60 years of age with diverse mental and physical health symptoms. All participants identified as sexual minorities, gender minorities or both. Thematic analysis revealed challenges to diagnosis. Provider-level challenges included pathologisation of SGM identity; dismissal of symptoms due to anti-SGM bias; communication failures due to providers being distracted by SGM identity and enforcement of cis-heteronormative assumptions. Patient-level challenges included internalised shame and stigma. Intersectional challenges included biases around factors like race and age. Patient-reported diagnostic error led to worsening relationships with providers, worsened mental and physical health and increased self-advocacy and community-activism. Solutions to reduce diagnostic disparities included SGM-specific medical education and provider training, using inclusive language, asking questions, avoiding assumptions, encouraging diagnostic coproduction, upholding high care standards and ethics, involving SGM individuals in healthcare improvement and increasing research on SGM health. CONCLUSIONS Anti-SGM bias, queerphobia, lack of provider training and heteronormative attitudes hinder diagnostic decision-making and communication. As a result, SGM patients report significant harms. Solutions to mitigate diagnostic disparities require an intersectional approach that considers patients' gender identity, sexual orientation, race, age, economic status and system-level changes.
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Affiliation(s)
- Aaron A Wiegand
- Johns Hopkins University School of Nursing, Baltimore, Maryland, USA
- Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | | | | | - Vadim Dukhanin
- Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Kathryn M McDonald
- Johns Hopkins University School of Nursing, Baltimore, Maryland, USA
- Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Miller AC, Cavanaugh JE, Arakkal AT, Koeneman SH, Polgreen PM. A comprehensive framework to estimate the frequency, duration, and risk factors for diagnostic delays using bootstrapping-based simulation methods. BMC Med Inform Decis Mak 2023; 23:68. [PMID: 37060037 PMCID: PMC10103428 DOI: 10.1186/s12911-023-02148-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 03/15/2023] [Indexed: 04/16/2023] Open
Abstract
BACKGROUND The incidence of diagnostic delays is unknown for many diseases and specific healthcare settings. Many existing methods to identify diagnostic delays are resource intensive or difficult to apply to different diseases or settings. Administrative and other real-world data sources may offer the ability to better identify and study diagnostic delays for a range of diseases. METHODS We propose a comprehensive framework to estimate the frequency of missed diagnostic opportunities for a given disease using real-world longitudinal data sources. We provide a conceptual model of the disease-diagnostic, data-generating process. We then propose a bootstrapping method to estimate measures of the frequency of missed diagnostic opportunities and duration of delays. This approach identifies diagnostic opportunities based on signs and symptoms occurring prior to an initial diagnosis, while accounting for expected patterns of healthcare that may appear as coincidental symptoms. Three different bootstrapping algorithms are described along with estimation procedures to implement the resampling. Finally, we apply our approach to the diseases of tuberculosis, acute myocardial infarction, and stroke to estimate the frequency and duration of diagnostic delays for these diseases. RESULTS Using the IBM MarketScan Research databases from 2001 to 2017, we identified 2,073 cases of tuberculosis, 359,625 cases of AMI, and 367,768 cases of stroke. Depending on the simulation approach that was used, we estimated that 6.9-8.3% of patients with stroke, 16.0-21.3% of patients with AMI and 63.9-82.3% of patients with tuberculosis experienced a missed diagnostic opportunity. Similarly, we estimated that, on average, diagnostic delays lasted 6.7-7.6 days for stroke, 6.7-8.2 days for AMI, and 34.3-44.5 days for tuberculosis. Estimates for each of these measures was consistent with prior literature; however, specific estimates varied across the different simulation algorithms considered. CONCLUSIONS Our approach can be easily applied to study diagnostic delays using longitudinal administrative data sources. Moreover, this general approach can be customized to fit a range of diseases to account for specific clinical characteristics of a given disease. We summarize how the choice of simulation algorithm may impact the resulting estimates and provide guidance on the statistical considerations for applying our approach to future studies.
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Affiliation(s)
- Aaron C Miller
- Department of Internal Medicine, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA, 52242, USA.
| | - Joseph E Cavanaugh
- Department of Biostatistics, College of Public Health, University of Iowa, Iowa City, IA, 52242, USA
| | - Alan T Arakkal
- Department of Biostatistics, College of Public Health, University of Iowa, Iowa City, IA, 52242, USA
| | - Scott H Koeneman
- Department of Biostatistics, College of Public Health, University of Iowa, Iowa City, IA, 52242, USA
| | - Philip M Polgreen
- Department of Internal Medicine, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA, 52242, USA
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Nakai H, Sakamoto R, Kakigi T, Coeur C, Isoda H, Nakamoto Y. Artificial intelligence-powered software detected more than half of the liver metastases overlooked by radiologists on contrast-enhanced CT. Eur J Radiol 2023; 163:110823. [PMID: 37059006 DOI: 10.1016/j.ejrad.2023.110823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 02/17/2023] [Accepted: 04/04/2023] [Indexed: 04/16/2023]
Abstract
PURPOSE To evaluate the sensitivity of artificial intelligence (AI)-powered software in detecting liver metastases, especially those overlooked by radiologists. METHODS Records of 746 patients diagnosed with liver metastases (November 2010-September 2017) were reviewed. Images from when radiologists first diagnosed liver metastases were reviewed, and prior contrast-enhanced CT (CECT) images were checked for availability. Two abdominal radiologists classified the lesions into overlooked lesions (all metastases missed by radiologists on prior CECT) and detected lesions (all metastases if any of them were correctly identified and invisible on prior CECT or those with no prior CECT). Finally, images from 137 patients were identified, 68 of which were classified as "overlooked cases." The same radiologists created the ground truth for these lesions and compared them with the software's output at 2-month intervals. The primary endpoint was the sensitivity in detecting all liver lesion types, liver metastases, and liver metastases overlooked by radiologists. RESULTS The software successfully processed images from 135 patients. The per-lesion sensitivity for all liver lesion types, liver metastases, and liver metastases overlooked by radiologists was 70.1%, 70.8%, and 55.0%, respectively. The software detected liver metastases in 92.7% and 53.7% of patients in detected and overlooked cases, respectively. The average number of false positives was 0.48 per patient. CONCLUSION The AI-powered software detected more than half of liver metastases overlooked by radiologists while maintaining a relatively low number of false positives. Our results suggest the potential of AI-powered software in reducing the frequency of overlooked liver metastases when used in conjunction with the radiologists' clinical interpretation.
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Affiliation(s)
- Hirotsugu Nakai
- Department of Diagnostic Imaging and Nuclear Medicine, Kyoto University Graduate School of Medicine, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan.
| | - Ryo Sakamoto
- Department of Diagnostic Imaging and Nuclear Medicine, Kyoto University Graduate School of Medicine, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan; Preemptive Medicine and Lifestyle Disease Research Center, Kyoto University Hospital, 53 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan.
| | - Takahide Kakigi
- Department of Diagnostic Imaging and Nuclear Medicine, Kyoto University Graduate School of Medicine, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan.
| | - Christophe Coeur
- AI digital division - Guerbet, 15 Rue des Vanesses, Villepinte 93420, France.
| | - Hiroyoshi Isoda
- Department of Diagnostic Imaging and Nuclear Medicine, Kyoto University Graduate School of Medicine, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan; Preemptive Medicine and Lifestyle Disease Research Center, Kyoto University Hospital, 53 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan.
| | - Yuji Nakamoto
- Department of Diagnostic Imaging and Nuclear Medicine, Kyoto University Graduate School of Medicine, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan.
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Pinto R, Hampton T, De S, Donne A. Foreign body impaction of the hard palate: tabletop party confetti mimicking button batteries in two infants. Eur Arch Otorhinolaryngol 2023; 280:3023-3026. [PMID: 36997803 DOI: 10.1007/s00405-023-07935-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 03/17/2023] [Indexed: 04/01/2023]
Abstract
We present the first two cases in the literature of tabletop party confetti mimicking button batteries in two infants. Both patients presented to the Emergency Department with an incidentally noticed shiny, metallic appearing, disc-shaped foreign body impacted in the hard palate. Both objects were understandably misdiagnosed as button batteries. The first patient required foreign body retrieval by ENT under general anaesthesia, whilst the second underwent retrieval safely in the Emergency Department. Tabletop party confetti should be considered in patients presenting with a suspected button battery impaction of the hard palate, which will drastically change the approach to clinical management and potentially minimise harms.
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Affiliation(s)
- Rohan Pinto
- ENT Department, Alder Hey Children's NHS Foundation Trust, E Prescot Rd, Liverpool, L14 5AB, Merseyside, UK
| | - Thomas Hampton
- ENT Department, Alder Hey Children's NHS Foundation Trust, E Prescot Rd, Liverpool, L14 5AB, Merseyside, UK.
- Institute of Life Course and Medical Sciences, University of Liverpool, Brownlow Hill, Liverpool, L69 3BX, Merseyside, UK.
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Pl, Liverpool, L3 5QA, Merseyside, UK.
| | - Su De
- ENT Department, Alder Hey Children's NHS Foundation Trust, E Prescot Rd, Liverpool, L14 5AB, Merseyside, UK
| | - Adam Donne
- ENT Department, Alder Hey Children's NHS Foundation Trust, E Prescot Rd, Liverpool, L14 5AB, Merseyside, UK
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Jo EA, Seong S, Ahn S, Mo H, Jung IM, Kim HK, Ko H, Han A, Min S, Min SK. Validation of I71.3 code for ruptured abdominal aortic aneurysm in Korea: misplaced diagnosis in claims data. Ann Surg Treat Res 2023; 104:170-175. [PMID: 36910559 PMCID: PMC9998958 DOI: 10.4174/astr.2023.104.3.170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 12/19/2022] [Accepted: 01/05/2023] [Indexed: 03/09/2023] Open
Abstract
Purpose Studies in western countries have shown a decline in the incidence of ruptured abdominal aortic aneurysm (rAAA) with advancements in endovascular repair and screening. However, according to health insurance data in Korea based on rAAA code (I71.3), overall rAAA has been increasing. This study aimed to validate the I71.3 code for rAAA and attempt to define the true incidence of rAAA in Korea. Methods A 20-year multicenter retrospective review of rAAA was undertaken from the period of January 1, 2000 to December 31, 2020. All patients were diagnosed with the rAAA code I71.3 in each of the 4 hospitals. The CT images and surgical records of these patients were reviewed to differentiate true rAAA and misdiagnosis. Further data on true rAAA patient outcomes including mortality and treatment success were also collected. Results A total of 305 rAAA (I71.3) codes were identified in the 4 centers. However, medical record review showed true rAAA in only 131 (43.0%). The remaining 174 cases (57.0%) were misdiagnosed. Impending ruptures were the most common misdiagnoses (37.9%). The total in-hospital mortality including deaths before treatment was 38.9% (n = 51), while mortality of treated patients was 24.4% (n = 15). Conclusion The analysis of I71.3 code for rAAA showed that only 43.0% were true rAAA and the remaining 57.0% were misdiagnosed. This indicates that the I71.3 code is overestimated in National Health Insurance-based data and that the true incidence of rAAA could be much lower.
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Affiliation(s)
- Eun-Ah Jo
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Sujeong Seong
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Sanghyun Ahn
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Hyejin Mo
- Department of Surgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
| | - In-Mok Jung
- Department of Surgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
| | - Hyo Kee Kim
- Department of Surgery, Korea University Guro Hospital, Seoul, Korea
| | - Hyunmin Ko
- Department of Surgery, Kyung Hee University Medical Center, Seoul, Korea
| | - Ahram Han
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Sangil Min
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Seung-Kee Min
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
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Pastrana-Arellano E, Valdés-Loperena S, Vargas-Flores Y, Durán-McKinster C, García-Romero MT. Concordance between referral and final diagnoses of pediatric patients with vascular malformations. Bol Med Hosp Infant Mex 2023; 80:53-56. [PMID: 36867573 DOI: 10.24875/bmhim.22000149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023] Open
Abstract
BACKGROUND Vascular malformations (VaM) are a heterogeneous group of disorders resulting from the dysmorphogenesis of blood vessels. Although correct classification is relevant to providing adequate treatment according to evidence-based medicine, diagnostic terminology may be misused or need clarification. METHODS We conducted a retrospective study to measure agreement and concordance between referral and final confirmed diagnoses of 435 pediatric patients with VaM newly referred to the multidisciplinary Vascular Anomalies Clinic (VAC) using Fleiss kappa (κ) concordance analysis. RESULTS We found fair concordance between referral and confirmed diagnoses of VaM (κ 0.306, p < 0.001). Lymphatic malformations (LM) and VaM associated with other anomalies showed moderate diagnostic concordance (κ 0.593, p < 0.001 and κ 0.469, p < 0.001, respectively). CONCLUSIONS Continuing medical education strategies are required to improve physician knowledge and diagnostic accuracy in patients with VaM.
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Affiliation(s)
| | | | - Yaneli Vargas-Flores
- Departamento de Dermatología, Instituto Nacional de Pediatría, Mexico City, Mexico
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Abstract
There are typically three phases identified as contributing to the total testing process. The preanalytical phase starts with the clinician and the patient, when laboratory testing is being considered. This phase also includes decisions about which tests to order (or not), patient identification, blood collection, blood transport, sample processing, and storage to name a few. There are many potential failures that may occur in this preanalytical phase, and these are the topic of another chapter in this book. The second phase, the analytical phase, represents the performance of the test, which is essentially covered in various protocols in this book and the previous edition. The third is the post-analytical phase, which is what occurs after sample testing, and is the topic of the current chapter. Post-analytical issues are generally related to reporting and interpretation of test results. This chapter provides a brief description of these events, as well as guidance for preventing or minimizing post-analytical issues. In particular, there are several strategies for improved post-analytical reporting of hemostasis assays, with this providing the final opportunity to prevent serious clinical errors in patient diagnosis or management.
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Affiliation(s)
- Emmanuel J Favaloro
- School of Medical Sciences, Faculty of Medicine and Health University of Sydney, Westmead Hospital, Westmead, NSW, Australia.
- School of Dentistry and Medical Sciences, Faculty of Science and Health, Charles Sturt University, Wagga, Wagga, NSW, Australia.
| | - Robert C Gosselin
- Hemostasis & Thrombosis Center, University of California, Davis Health System, Sacramento, CA, USA
| | - Leonardo Pasalic
- Department of Haematology, Sydney Centres for Thrombosis and Haemostasis, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital, Westmead, NSW, Australia
- Westmead Clinical School, University of Sydney, Westmead, NSW, Australia
| | - Giuseppe Lippi
- Section of Clinical Biochemistry, University of Verona, Verona, Italy
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El-Wakeel N, Ezzeldin N. Diagnostic errors in Dentistry, opinions of egyptian dental teaching staff, a cross-sectional study. BMC Oral Health 2022; 22:621. [PMID: 36539763 PMCID: PMC9764576 DOI: 10.1186/s12903-022-02565-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 11/05/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Diagnostic errors is a known problem in healthcare practice. Data on diagnostic errors in the dental field are extremely lacking. The objective of the study is to explore the perception of dental teaching staff about the prevalence of dental diagnostic errors in Egypt, identify the most commonly misdiagnosed dental conditions and point out the contributing factors and levels of patient harm. METHODS A cross-sectional questionnaire-based study was conducted on 151 dental teaching staff of Egyptian governmental and private universities. The questionnaire was distributed electronically via social media and messaging apps to dental staff members with at least five years of clinical experience to assess their opinion regarding the study objectives. Results were collected and statistically analyzed. RESULTS 94.7% of participants believed that diagnostic errors represent an urgent problem, lecturers believed by 2.703 folds more than professors that diagnostic errors are an urgent problem The percentage of diagnostic errors was estimated to be < 20% and 20-40% by more than 90% of participants. The most commonly misdiagnosed conditions were oral mucosal lesions (83.4%), followed by temporomandibular joint and periodontal conditions (58.9%) for each. More than half of the participants (60.9%) believe that medical education methodology is one of the factors that lead to dental diagnosis errors. For the impact of errors on patients, 53% of participants reported moderate impacts followed by minor impact (37.7%) while 4.6% reported no impact and the same percentage reported major impact. CONCLUSION This study with statistically significant results reported that dental diagnostic errors are frequent and need to be approached. Oral mucosal lesions, periodontal and temporomandibular joint diseases represent areas that include the most commonly seen errors. Further, besides the lack of resources, the dental education system and lack of proper training are the main causes of this problem.
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Affiliation(s)
- Naglaa El-Wakeel
- grid.411303.40000 0001 2155 6022Oral medicine and Periodontology department, Faculty of Dentistry, Al-Azhar University (Girls Branch), Cairo, Egypt
| | - Naglaa Ezzeldin
- grid.442760.30000 0004 0377 4079Pediatric Dentistry, Faculty of Dentistry, October University for Modern Sciences and Arts, Cairo, Egypt
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van Sassen CGM, van den Berg PJ, Mamede S, Knol L, Eikens-Jansen MP, van den Broek WW, Bindels PJE, Zwaan L. Identifying and prioritizing educational content from a malpractice claims database for clinical reasoning education in the vocational training of general practitioners. Adv Health Sci Educ Theory Pract 2022:10.1007/s10459-022-10194-8. [PMID: 36529764 DOI: 10.1007/s10459-022-10194-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 11/27/2022] [Indexed: 06/17/2023]
Abstract
Diagnostic reasoning is an important topic in General Practitioners' (GPs) vocational training. Interestingly, research has paid little attention to the content of the cases used in clinical reasoning education. Malpractice claims of diagnostic errors represent cases that impact patients and that reflect potential knowledge gaps and contextual factors. With this study, we aimed to identify and prioritize educational content from a malpractice claims database in order to improve clinical reasoning education in GP training. With input from various experts in clinical reasoning and diagnostic error, we defined five priority criteria that reflect educational relevance. Fifty unique medical conditions from a malpractice claims database were scored on those priority criteria by stakeholders in clinical reasoning education in 2021. Subsequently, we calculated the mean total priority score for each condition. Mean total priority score (min 5-max 25) for all fifty diagnoses was 17,11 with a range from 13,89 to 19,61. We identified and described the fifteen highest scoring diseases (with priority scores ranging from 18,17 to 19,61). The prioritized conditions involved complex common (e.g., cardiovascular diseases, renal insufficiency and cancer), complex rare (e.g., endocarditis, ectopic pregnancy, testicular torsion) and more straightforward common conditions (e.g., tendon rupture/injury, eye infection). The claim cases often demonstrated atypical presentations or complex contextual factors. Including those malpractice cases in GP vocational training could enrich the illness scripts of diseases that are at high risk of errors, which may reduce diagnostic error and related patient harm.
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Affiliation(s)
- Charlotte G M van Sassen
- Department of General Practice, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands.
- Institute of Medical Education Research Rotterdam (iMERR), Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands.
| | - Pieter J van den Berg
- Department of General Practice, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Silvia Mamede
- Institute of Medical Education Research Rotterdam (iMERR), Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Psychology, Education and Child Studies, Erasmus School of Social and Behavioral Sciences, Rotterdam, The Netherlands
| | - Lilian Knol
- VvAA, Orteliuslaan 750, 3528 BB, Utrecht, The Netherlands
| | | | - Walter W van den Broek
- Institute of Medical Education Research Rotterdam (iMERR), Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Patrick J E Bindels
- Department of General Practice, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Laura Zwaan
- Institute of Medical Education Research Rotterdam (iMERR), Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
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Cook DA, Stephenson CR, Gruppen LD, Durning SJ. Management reasoning scripts: Qualitative exploration using simulated physician-patient encounters. Perspect Med Educ 2022; 11:196-206. [PMID: 35653028 PMCID: PMC9391545 DOI: 10.1007/s40037-022-00714-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 04/23/2022] [Accepted: 04/26/2022] [Indexed: 06/15/2023]
Abstract
INTRODUCTION Management reasoning is distinct from diagnostic reasoning and remains incompletely understood. The authors sought to empirically investigate the concept of management scripts. METHODS In November 2020, 4 investigators each reviewed 10 video clips of simulated outpatient physician-patient encounters, and used a coding form to document observations about management reasoning. The team used constant comparative analysis to integrate empirically-grounded insights with theories related to cognitive scripts and Type 1/Type 2 thinking. RESULTS Management scripts are precompiled conceptual knowledge structures that represent and connect management options and clinician tasks in a temporal or logical sequence. Management scripts appear to differ substantially from illness scripts. Management scripts varied in quality (in content, sequence, flexibility, and fluency) and generality. The authors empirically identified six key features (components) of management scripts: the problem (diagnosis); management options; preferences, values, and constraints; education needs; interactions; and encounter flow. The authors propose a heuristic framework describing script activation, selection, instantiation with case-specific details, and application to guide development of the management plan. They further propose that management reasoning reflects iterative, back-and-forth involvement of both Type 1 (non-analytic, effortless) and Type 2 (analytic, effortful) thinking. Type 1 thinking likely influences initial script activation, selection, and initial instantiation. Type 2 increasingly influences subsequent script revisions, as activation, selection, and instantiation become more deliberate (effortful) and more hypothetical (involving mental simulation). DISCUSSION Management scripts constitute a key feature of management reasoning, and could represent a new target for training in clinical reasoning (distinct from illness scripts).
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Affiliation(s)
- David A Cook
- Office of Applied Scholarship and Education Science, Mayo Clinic College of Medicine and Science, Rochester, MN, USA.
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA.
| | | | - Larry D Gruppen
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI, USA
| | - Steven J Durning
- Center for Health Professions Education, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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Budigi B, Oliphant M, Itri J. Pancreatic Adenocarcinoma: Diagnostic Errors, Contributing Factors and Solutions. Acad Radiol 2022; 29:967-976. [PMID: 34838452 DOI: 10.1016/j.acra.2021.10.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 10/18/2021] [Accepted: 10/27/2021] [Indexed: 12/12/2022]
Abstract
The purpose of this article is to review diagnostic errors in preoperative and post-operative imaging for pancreatic ductal adenocarcinoma (PDAC), discuss contributing factors, and provide solutions that minimize errors. Accurate radiological staging and restaging of PDAC dictates surgical management and errors can have significant negative effects on patient care, such as missed vessel involvement or metastatic disease that would preclude surgery. Familiarity with these errors and their contributing factors improves diagnostic accuracy and ultimately leads to improved patient outcomes.
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Affiliation(s)
- Bhavana Budigi
- Department of Radiology, Division of Abdominal Imaging, Wake Forest Baptist Medical Center, 1 Medical Center Boulevard, Winston-Salem, NC 27157.
| | - Michael Oliphant
- Department of Radiology, Division of Abdominal Imaging, Wake Forest Baptist Medical Center, 1 Medical Center Boulevard, Winston-Salem, NC 27157
| | - Jason Itri
- Department of Radiology, Division of Abdominal Imaging, Wake Forest Baptist Medical Center, 1 Medical Center Boulevard, Winston-Salem, NC 27157
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Nguyen HB, Nguyen TKL, Ung TT, Mai TTN, Tran TNH, Ngo VQT, Le VA. Case of misdiagnosed melioidosis from Hue city, Vietnam. Iran J Microbiol 2022; 14:430-433. [PMID: 37124859 PMCID: PMC10132338 DOI: 10.18502/ijm.v14i3.9796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
Melioidosis is an emerging infection, a potentially fatal tropical disease caused by Burkholderia pseudomallei in humans and animals, endemic in Southeast Asia and northern Australia. Diagnosis remains problematic due to its similarity to many other infections. The lack of clinical awareness and correct microbiological diagnosis contributes to the misidentification of melioidosis. We present a melioidosis case, which was misdiagnosed with pneumonia and septicemia due to Aeromonas salmonicida, leading to ineffective prolonged-course antibiotic treatment for the patient.
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Affiliation(s)
- Hoang Bach Nguyen
- Department of Microbiology, Hue University of Medicine and Pharmacy, Hue University, Hue, Vietnam
- Corresponding author: Hoang Bach Nguyen, Ph.D, Department of Microbiology, Hue University of Medicine and Pharmacy, Hue University, Hue, Vietnam. Tel: +84-983303187 Fax: +84-2343826269
| | - Thi Khanh Linh Nguyen
- Department of Microbiology, Hue University of Medicine and Pharmacy, Hue University, Hue, Vietnam
| | - Thi Thuy Ung
- Department of Microbiology, Hue University of Medicine and Pharmacy, Hue University, Hue, Vietnam
| | - Thi Thao Nhi Mai
- Department of Basic Internal Medicine, Phan Chau Trinh University, Quang Nam, Vietnam
| | - Thi Nhu Hoa Tran
- Department of Microbiology, Hue University of Medicine and Pharmacy, Hue University, Hue, Vietnam
| | - Viet Quynh Tram Ngo
- Department of Microbiology, Hue University of Medicine and Pharmacy, Hue University, Hue, Vietnam
| | - Van An Le
- Department of Microbiology, Hue University of Medicine and Pharmacy, Hue University, Hue, Vietnam
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Coen M, Sader J, Junod-Perron N, Audétat MC, Nendaz M. Clinical reasoning in dire times. Analysis of cognitive biases in clinical cases during the COVID-19 pandemic. Intern Emerg Med 2022; 17:979-988. [PMID: 34997906 PMCID: PMC8742156 DOI: 10.1007/s11739-021-02884-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Accepted: 11/01/2021] [Indexed: 11/13/2022]
Abstract
Cognitive biases are systematic cognitive distortions, which can affect clinical reasoning. The aim of this study was to unravel the most common cognitive biases encountered in in the peculiar context of the COVID-19 pandemic. Case study research design. Primary care. Single centre (Division of General Internal Medicine, University Hospitals of Geneva, Geneva, Switzerland). A short survey was sent to all primary care providers (N = 169) taking care of hospitalised adult patients with COVID-19. Participants were asked to describe cases in which they felt that their clinical reasoning was "disrupted" because of the pandemic context. Seven case were sufficiently complete to be analysed. A qualitative analysis of the clinical cases was performed and a bias grid encompassing 17 well-known biases created. The clinical cases were analyzed to assess for the likelihood (highly likely, plausible, not likely) of the different biases for each case. The most common biases were: "anchoring bias", "confirmation bias", "availability bias", and "cognitive dissonance". The pandemic context is a breeding ground for the emergence of cognitive biases, which can influence clinical reasoning and lead to errors. Awareness of these cognitive mechanisms could potentially reduce biases and improve clinical reasoning. Moreover, the analysis of cognitive biases can offer an insight on the functioning of the clinical reasoning process in the midst of the pandemic crisis.
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Affiliation(s)
- Matteo Coen
- grid.8591.50000 0001 2322 4988Unit of Development and Research in Medical Education, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- grid.150338.c0000 0001 0721 9812Division of General Internal Medicine, Department of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Julia Sader
- grid.8591.50000 0001 2322 4988Unit of Development and Research in Medical Education, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- grid.8591.50000 0001 2322 4988iEh2-Institute for Ethics, History, and the Humanities-Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Noëlle Junod-Perron
- grid.8591.50000 0001 2322 4988Unit of Development and Research in Medical Education, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Marie-Claude Audétat
- grid.8591.50000 0001 2322 4988Unit of Development and Research in Medical Education, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- grid.8591.50000 0001 2322 4988Institute of Primary Care (IuMFE), Faculty of Medicine, University of Geneva, Geneva, Switzerland
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Stockwell DC, Sharek P. Diagnosing diagnostic errors: it's time to evolve the patient safety research paradigm. BMJ Qual Saf 2022; 31:701-703. [PMID: 35508375 DOI: 10.1136/bmjqs-2021-014517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2022] [Indexed: 11/04/2022]
Affiliation(s)
- David C Stockwell
- Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, USA .,Chief Medical Officer, Johns Hopkins Children's Center, Baltimore, Maryland, USA
| | - Paul Sharek
- General Pediatrics and Hospital Medicine, University of Washington, Seattle, Washington, USA.,Vice President, Chief Quality and Safety Officer, Seattle Children's Hospital, Seattle, Washington, USA
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Pinto A, Lanzetta MM, Addeo G, Bonini MC, Grazzini G, Miele V. Errors in MDCT diagnosis of acute mesenteric ischemia. Abdom Radiol (NY) 2022; 47:1699-1713. [PMID: 32918107 DOI: 10.1007/s00261-020-02732-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 08/17/2020] [Accepted: 08/30/2020] [Indexed: 01/17/2023]
Abstract
The causes of diagnostic errors during daily medical practice can be several, mainly attributable to perceptual, interpretive and communication factors. The eventuality of radiological error is much more amplified in the emergency setting where a high number of complex multidetector-row computed tomography (MDCT) images must be evaluated quickly and critical time decisions need to be taken. In particular, in this context, the diagnosis of vascular intestinal diseases represents a crucial and difficult challenge in case of acute abdominal pain given the importance of being able to identify patient with high suspicious for intestinal ischemia and for a specific patient to judge if his ischemia is reversible or irreversible. Awareness of potential biases which can lead to diagnostic errors together with an extensive knowledge of the imaging features of these pathologies can lead to promptly recognize them with fewer mistakes, improving patients' outcome. This article reviews the MDCT findings of acute intestinal ischemia and acute colonic ischemia and analyzes the main types of diagnostic errors, underlining the importance of being familiarized with them to avoid misdiagnosis.
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Affiliation(s)
- Antonio Pinto
- Department of Radiology, CTO Hospital, Azienda Ospedaliera dei Colli, Naples, Italy
| | - Monica Marina Lanzetta
- Department of Emergency Radiology, Azienda Ospedaliero Universitaria Careggi, L.go G.A. Brambilla, 3, 50134, Florence, Italy
| | - Gloria Addeo
- Department of Emergency Radiology, Azienda Ospedaliero Universitaria Careggi, L.go G.A. Brambilla, 3, 50134, Florence, Italy.
| | - Maria Cristina Bonini
- Department of Emergency Radiology, Azienda Ospedaliero Universitaria Careggi, L.go G.A. Brambilla, 3, 50134, Florence, Italy
| | - Giulia Grazzini
- Department of Emergency Radiology, Azienda Ospedaliero Universitaria Careggi, L.go G.A. Brambilla, 3, 50134, Florence, Italy
| | - Vittorio Miele
- Department of Emergency Radiology, Azienda Ospedaliero Universitaria Careggi, L.go G.A. Brambilla, 3, 50134, Florence, Italy
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45
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Tausendfreund O, Braun LT, Schmidmaier R. Types of therapeutic errors in the management of osteoporosis made by physicians and medical students. BMC Med Educ 2022; 22:323. [PMID: 35473636 PMCID: PMC9044589 DOI: 10.1186/s12909-022-03384-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 04/11/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Clinical reasoning is of high importance in clinical practice and thus in medical education research. Regarding the clinical reasoning process, the focus has primarily been on diagnostic reasoning and diagnostic errors, but little research has been done on the subsequent management reasoning process, although the therapeutic decision-making process is at least equally important. The aim of this study was to investigate the frequency of therapeutic decision errors and the cognitive factors leading to these errors in the context of osteoporosis, as it is known to be frequently associated with inadequate treatment decisions in clinical practice worldwide. METHODS In 2019, 19 medical students and-for comparison-23 physicians worked on ten patient cases with the medical encounter of osteoporosis. A total of 254 cases were processed. The therapeutic decision errors were quantitatively measured, and the participants' cognitive contributions to therapeutic errors and their clinical consequences were qualitatively analysed. RESULTS In 26% of the cases, all treatment decisions were correct. In the remaining 74% cases, multiple errors occurred; on average, 3 errors occurred per case. These 644 errors were further classified regarding the cognitive contributions to the error. The most common cognitive contributions that led to errors were faulty context generation and interpretation (57% of students, 57% of physicians) and faulty knowledge (38% of students, 35% of physicians). Errors made due to faulty metacognition (5% of students, 8% of physicians) were less common. Consequences of these errors were false therapy (37% of cases), undertreatment (30% of cases) or overtreatment (2.5% of cases). CONCLUSION The study is the first to show that errors in therapy decisions can be distinguished and classified, similar to the already known classification for errors in diagnostic reasoning. Not only the correct diagnosis, but particularly the correct therapy, is critical for the outcome of a patient.
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Affiliation(s)
- Olivia Tausendfreund
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ziemssenstr. 5, 80336 Munich, Germany
| | - Leah T. Braun
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ziemssenstr. 5, 80336 Munich, Germany
| | - Ralf Schmidmaier
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ziemssenstr. 5, 80336 Munich, Germany
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46
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Hoda RS, Brogi E, Wen HY. Quality Issues in Diagnostic Immunohistochemistry in Breast Pathology. Pathobiology 2022; 89:324-333. [PMID: 35443240 DOI: 10.1159/000522538] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 01/31/2022] [Indexed: 11/19/2022] Open
Abstract
Immunohistochemistry techniques have been incorporated into surgical pathology for nearly a half-century and have since become intimately intertwined with its practice. In the realm of breast pathology, immunohistochemistry serves several purposes, including providing crucial prognostic and predictive data. Among its other applications, assessment of stromal invasion and establishment of mammary origin are crucial from a diagnostic standpoint. In these regards, sole reliance on immunohistochemistry may lead to misdiagnosis. In this review, we highlight pitfalls of immunohistochemistry commonly encountered in the practice of breast pathology and emphasize the importance of careful histopathological evaluation.
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Affiliation(s)
- Raza S Hoda
- Robert J Tomsich Pathology & Laboratory Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Edi Brogi
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Hannah Y Wen
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York, USA,
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47
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Bamberger E, Bamberger P. Unacceptable behaviours between healthcare workers: just the tip of the patient safety iceberg. BMJ Qual Saf 2022; 31:638-641. [PMID: 35428683 DOI: 10.1136/bmjqs-2021-014157] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2022] [Indexed: 11/04/2022]
Affiliation(s)
- Ellen Bamberger
- Technion Israel Institute of Technology The Ruth and Bruce Rappaport Faculty of Medicine, Haifa, Israel.,Pediatrics, Bnai Zion Medical Center, Haifa, Israel
| | - Peter Bamberger
- Coller School of Management, Tel Aviv University, Tel Aviv, Israel
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48
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Khoong EC, Sharma AE, Gupta K, Adler-Milstein J, Sarkar U. The Abrupt Expansion of Ambulatory Telemedicine: Implications for Patient Safety. J Gen Intern Med 2022; 37:1270-1274. [PMID: 35048294 PMCID: PMC8768444 DOI: 10.1007/s11606-021-07329-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 12/14/2021] [Indexed: 11/28/2022]
Abstract
The exponential growth of telemedicine in ambulatory care triggered by the COVID-19 public health emergency has undoubtedly impacted the quality of care and patient safety. In particular, the increased adoption of remote care has impacted communication, care teams, and patient engagement, which are key factors that impact patient safety in ambulatory care. In this perspective, we draw on a scoping review of the literature, our own clinical experiences, and conversations with patient safety experts to describe how changes in communication, care teams, and patient engagement have impacted two high priority areas in ambulatory safety: diagnostic errors and medication safety. We then provide recommendations for research funders, researchers, healthcare systems, policy makers, and healthcare payors for how to improve patient safety in telemedicine based on what is currently known as well as next steps for how to advance understanding of the safety implications of telemedicine utilization.
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Affiliation(s)
- Elaine C Khoong
- Division of General Internal Medicine at Zuckerberg San Francisco General Hospital, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
- UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital, San Francisco, USA
| | - Anjana E Sharma
- UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital, San Francisco, USA
- Department of Family and Community Medicine, University of California San Francisco, San Francisco, USA
| | - Kiran Gupta
- Division of Hospital Medicine, Department of Medicine, University of California San Francisco, San Francisco, USA
| | - Julia Adler-Milstein
- Center for Clinical Informatics and Improvement Research (CLIIR) at University of California San Francisco, San Francisco, USA
- Department of Medicine, University of California San Francisco, San Francisco, USA
| | - Urmimala Sarkar
- Division of General Internal Medicine at Zuckerberg San Francisco General Hospital, Department of Medicine, University of California San Francisco, San Francisco, CA, USA.
- UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital, San Francisco, USA.
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49
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Zhuang L, Su J, Tu P. Cutaneous leishmaniasis presenting with painless ulcer on the right forearm: A case report. World J Clin Cases 2022; 10:2301-2306. [PMID: 35321164 PMCID: PMC8895175 DOI: 10.12998/wjcc.v10.i7.2301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 12/13/2021] [Accepted: 01/20/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Leishmaniasis includes a range of chronic infections in humans and animals and can be caused by more than 20 species of Leishmania protozoa. The manifestations of leishmaniasis are diverse and dependent on the immune response capacity of the host and the type of Leishmania. In East Asia, leishmaniasis is relatively rare and prone to misdiagnosis and underdiagnosis.
CASE SUMMARY We report a case of a 36-year-old male with cutaneous leishmaniasis. The patient had been misdiagnosed with a bacterial skin infection and was given a dressing change and oral levofloxacin, which proved ineffective. Histopathological examination revealed amastigote (Leishman-Donovan body) in the histocytes, and nucleic acid sequencing proved that the pathogen was Leishmania major. The patient was treated successfully by regional injection of sodium gluconate (600 mg) three times. The ulcer healed and did not recur at 1.5-year follow-up.
CONCLUSION Skin ulcers caused by leishmaniasis are easily misdiagnosed in non-epidemic countries, yet it should not be overlooked.
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Affiliation(s)
- Le Zhuang
- Department of Dermatology, Peking University The First Hospital, Beijing 100034, China
- Department of Dermatology, Qilu Hospital of Shandong University, Jinan 250012, Shandong province, China
| | - Jing Su
- Department of Pathology, School of Basic Medical Sciences, The Third Hospital, Peking University Health Science Center, Beijing 100034, China
| | - Ping Tu
- Department of Dermatology, Peking University The First Hospital, Beijing 100034, China
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50
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Hwang EJ, Park J, Hong W, Lee HJ, Choi H, Kim H, Nam JG, Goo JM, Yoon SH, Lee CH, Park CM. Artificial intelligence system for identification of false-negative interpretations in chest radiographs. Eur Radiol 2022; 32:4468-4478. [PMID: 35195744 DOI: 10.1007/s00330-022-08593-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 01/04/2022] [Accepted: 01/25/2022] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To investigate the efficacy of an artificial intelligence (AI) system for the identification of false negatives in chest radiographs that were interpreted as normal by radiologists. METHODS We consecutively collected chest radiographs that were read as normal during 1 month (March 2020) in a single institution. A commercialized AI system was retrospectively applied to these radiographs. Radiographs with abnormal AI results were then re-interpreted by the radiologist who initially read the radiograph ("AI as the advisor" scenario). The reference standards for the true presence of relevant abnormalities in radiographs were defined by majority voting of three thoracic radiologists. The efficacy of the AI system was evaluated by detection yield (proportion of true-positive identification among the entire examination) and false-referral rate (FRR, proportion of false-positive identification among all examinations). Decision curve analyses were performed to evaluate the net benefits of applying the AI system. RESULTS A total of 4208 radiographs from 3778 patients (M:F = 1542:2236; median age, 56 years) were included. The AI system identified initially overlooked relevant abnormalities with a detection yield and an FRR of 2.4% and 14.0%, respectively. In the "AI as the advisor" scenario, radiologists detected initially overlooked relevant abnormalities with a detection yield and FRR of 1.2% and 0.97%, respectively. In a decision curve analysis, AI as an advisor scenario exhibited a positive net benefit when the cost-to-benefit ratio was below 1:0.8. CONCLUSION An AI system could identify relevant abnormalities overlooked by radiologists and could enable radiologists to correct their false-negative interpretations by providing feedback to radiologists. KEY POINTS • In consecutive chest radiographs with normal interpretations, an artificial intelligence system could identify relevant abnormalities that were initially overlooked by radiologists. • The artificial intelligence system could enable radiologists to correct their initial false-negative interpretations by providing feedback to radiologists when overlooked abnormalities were present.
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Affiliation(s)
- Eui Jin Hwang
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea.,Department of Radiology, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
| | - Jongsoo Park
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
| | - Wonju Hong
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
| | - Hyun-Ju Lee
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea.,Department of Radiology, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
| | - Hyewon Choi
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea.,Department of Radiology, Chung-Ang University Hospital, 102 Heukseok-ro, Dongjak-gu, Seoul, 06973, Korea
| | - Hyungjin Kim
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea.,Department of Radiology, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
| | - Ju Gang Nam
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea.,Department of Radiology, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
| | - Jin Mo Goo
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea.,Department of Radiology, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
| | - Soon Ho Yoon
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea.,Department of Radiology, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
| | - Chang Hyun Lee
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea.,Department of Radiology, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
| | - Chang Min Park
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea. .,Department of Radiology, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Korea. .,Institute of Radiation Medicine, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea.
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