Incidence, origins and avoidable harm of missed opportunities in diagnosis: longitudinal patient record review in 21 English general practices

BackgroundDiagnostic error is a global patient safety priority.ObjectivesTo estimate the incidence, origins and avoidable harm of diagnostic errors in English general practice. Diagnostic errors were defined as missed opportunities to make a correct or timely diagnosis based on the evidence available (missed diagnostic opportunities, MDOs).MethodRetrospective medical record reviews identified MDOs in 21 general practices. In each practice, two trained general practitioner reviewers independently conducted case note reviews on 100 randomly selected adult consultations performed during 2013–2014. Consultations where either reviewer identified an MDO were jointly reviewed.ResultsAcross 2057 unique consultations, reviewers agreed that an MDO was possible, likely or certain in 89 cases or 4.3% (95% CI 3.6% to 5.2%) of reviewed consultations. Inter-reviewer agreement was higher than most comparable studies (Fleiss’ kappa=0.63). Sixty-four MDOs (72%) had two or more contributing process breakdowns. Breakdowns involved problems in the patient–practitioner encounter such as history taking, examination or ordering tests (main or secondary factor in 61 (68%) cases), performance and interpretation of diagnostic tests (31; 35%) and follow-up and tracking of diagnostic information (43; 48%). 37% of MDOs were rated as resulting in moderate to severe avoidable patient harm.ConclusionsAlthough MDOs occurred in fewer than 5% of the investigated consultations, the high numbers of primary care contacts nationally suggest that several million patients are potentially at risk of avoidable harm from MDOs each year. Causes of MDOs were frequently multifactorial, suggesting the need for development and evaluation of multipronged interventions, along with policy changes to support them.

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Primary care pediatricians’ interest in diagnostic error reduction

Diagnosis ◽

10.1515/dx-2015-0033 ◽

2016 ◽

Vol 3 (2) ◽

pp. 65-69 ◽

Cited By ~ 11

Author(s):

Michael L. Rinke ◽

Hardeep Singh ◽

Sarah Ruberman ◽

Jason Adelman ◽

Steven J. Choi ◽

...

Keyword(s):

Delayed Diagnosis ◽

Diagnostic Errors ◽

Diagnostic Error ◽

Error Reduction ◽

Self Report ◽

Abnormal Laboratory ◽

Electronic Survey ◽

Laboratory Values ◽

Life Threatening

Abstract: Diagnostic errors causing harm in children are understudied, resulting in a knowledge gap regarding pediatricians’ interest in reducing their incidence.: Electronic survey of general pediatricians focusing on diagnostic error incidence, errors they were interested in trying to improve, and errors reduced by their electronic health record (EHR).: Of 300 contacted pediatricians, 77 (26%) responded, 58 (19%) served ambulatory patients, and 48 (16%) completed the entire questionnaire. Of these 48, 17 (35%) reported making a diagnostic error at least monthly, and 16 (33%) reported making a diagnostic error resulting in an adverse event at least annually. Pediatricians were “most” interested in “trying to improve” missed diagnosis of hypertension (17%), delayed diagnosis due to missed subspecialty referral (15%), and errors associated with delayed follow-up of abnormal laboratory values (13%). Among the 44 pediatricians with an EHR, 16 (36%) said it reduced the likelihood of missing obesity and 14 (32%) said it reduced the likelihood of missing hypertension. Also, 15 (34%) said it helped avoid delays in follow-up of abnormal laboratory values. A third (36%) reported no help in diagnostic error reduction from their EHR.: Pediatricians self-report an appreciable number of diagnostic errors and were most interested in preventing high frequency, non-life-threatening errors. There exists a need to leverage EHRs to support error reduction efforts.

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Recommendations for using the Revised Safer Dx Instrument to help measure and improve diagnostic safety

Diagnosis ◽

10.1515/dx-2019-0012 ◽

2019 ◽

Vol 6 (4) ◽

pp. 315-323 ◽

Cited By ~ 8

Author(s):

Hardeep Singh ◽

Arushi Khanna ◽

Christiane Spitzmueller ◽

Ashley N.D. Meyer

Keyword(s):

Health Care ◽

Data Collection ◽

Medical Record ◽

Diagnostic Errors ◽

Diagnostic Error ◽

Diagnostic Process ◽

Sources Of Information ◽

Missed Opportunities ◽

Health Care Settings ◽

Data Collection Instrument

Abstract The medical record continues to be one of the most useful and accessible sources of information to examine the diagnostic process. However, medical record review studies of diagnostic errors have often used subjective judgments and found low inter-rater agreement among reviewers when determining the presence or absence of diagnostic error. In our previous work, we developed a structured data-collection instrument, called the Safer Dx Instrument, consisting of objective criteria to improve the accuracy of assessing diagnostic errors in primary care. This paper proposes recommendations on how clinicians and health care organizations could use the Revised Safer Dx Instrument in identifying and understanding missed opportunities to make correct and timely diagnoses. The instrument revisions addressed both methodological and implementation issues identified during initial use and included refinements to the instrument to allow broader application across all health care settings. In addition to leveraging knowledge from piloting the instrument in several health care settings, we gained insights from multiple researchers who had used the instrument in studies involving emergency care, inpatient care and intensive care unit settings. This allowed us to enhance and extend the scope of this previously validated data collection instrument. In this paper, we describe the refinement process and provide recommendations for application and use of the Revised Safer Dx Instrument across a broad range of health care settings. The instrument can help users identify potential diagnostic errors in a standardized way for further analysis and safety improvement efforts as well as provide data for clinician feedback and reflection. With wider adoption and use by clinicians and health systems, the Revised Safer Dx Instrument could help propel the science of measuring and reducing diagnostic errors forward.

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Failure to order and follow up medical tests are leading causes of diagnostic errors

PsycEXTRA Dataset ◽

10.1037/e504462010-007 ◽

2010 ◽

Keyword(s):

Diagnostic Errors ◽

Medical Tests

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Outcomes and Postoperative Complications of Robot-Assisted Laparoscopic Hysterosacropexy: Initial Experience

Urologia Internationalis ◽

10.1159/000371726 ◽

2015 ◽

Vol 95 (1) ◽

pp. 44-49 ◽

Cited By ~ 1

Author(s):

Maria Angela Cerruto ◽

Carolina D'Elia ◽

Francesca Maria Cavicchioli ◽

Stefano Cavalleri ◽

Matteo Balzarro ◽

...

Keyword(s):

Uterine Prolapse ◽

Pelvic Organ ◽

Consecutive Series ◽

Complication Rates ◽

Early Complications ◽

Robot Assisted ◽

Female Patients ◽

The Mean ◽

Record Review

Background: Pelvic organ prolapse is a common condition, affecting about 50% of women with children. The aim of our study was to evaluate results and complication rates in a consecutive series of female patients undergoing robot-assisted laparoscopic hysterosacropexy (RALHSP). Materials and Methods: We performed a medical record review of female patients with uterine prolapse who had consecutively undergone RALHSP from February 2010 to 2013 at our department. Results: Fifteen patients were included in the analysis. All patients had uterine prolapse stage ≥II and urodynamic stress urinary incontinence. The mean age was 58.26 years. According to the Clavien-Dindo system, 4 out of 15 patients (26.6%) had grade 1 early complications and 1 patient had a grade 2 complication. At a median follow-up of 36 months, there was a significant prolapse relapse rate of 20% (3/15). Conclusion: In our hands RALHSP is easy to perform, with satisfying mid-term outcomes and a low complication rate.

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Impacts of Faith-Based Lifestyle Interventions on Congregational-Level Nutrition and Physical Activity Environment and Policies

Current Developments in Nutrition ◽

10.1093/cdn/nzaa043_151 ◽

2020 ◽

Vol 4 (Supplement_2) ◽

pp. 300-300

Author(s):

Summer Wilmoth ◽

Leah Carrillo ◽

Elana Martinez ◽

Raymundo Mendoza Mendoza ◽

Lauren Correa ◽

...

Keyword(s):

Physical Activity ◽

Program Effectiveness ◽

San Antonio ◽

Macro Level ◽

Policy Changes ◽

Environment Policy ◽

Post Hoc Analysis ◽

Faith Based ◽

Post Hoc

Abstract Objectives Hispanics are disproportionally affected by obesity, cancer, and other obesity-related chronic diseases. Building a Healthy Temple (BHT) was a multi-component, faith-based lifestyle intervention implemented in 27 low-income, predominately-Hispanic congregations in San Antonio, TX between 2012 and 2017. One aim of BHT was to assess program effectiveness at improving health-conducive church environment/policy and sustainability of these improvements at follow-up. Methods A key macro-level program component of BHT was the formation of a Health Ministry Committee to initiate church-wide health-conducive environment/policy changes. The Congregational Health Index (CHI) was used to assess church nutrition (17 items) and physical activity (PA, 5 items) environment/policy at baseline, end of program, and follow-up (6 months or more post-intervention). Data were expressed as % of the maximum scores. Friedman test and post hoc analysis were performed with Wilcoxon signed-rank tests and significance of pairwise comparisons, adjusted with Bonferroni correction. Results Eighteen churches completed all 3 CHI assessments. Percentage of total nutrition and PA environment/policy scores for baseline, end of program, and follow-up were 38% (35–45), 64% (53–75), and 69% (64–77), respectively. Post hoc analysis shows significant improvements in nutrition and PA environment/policy scores at end of program (Z = –3.73, P < 0.001) and follow-up (Z = –3.73, P < 0.001) as compared to baseline, as well as significantly higher scores at follow-up compared to end of program (Z = –3.18, P = 0.001). Conclusions Study findings reveal the importance of utilizing congregation-wide macro-level interventions to create health-conducive enviroment/policy changes to facilitate and sustain healthy lifestyle changes in predominately-Hispanic faith community settings. Funding Sources Baptist Health Foundation San Antonio & Cancer Prevention Research Institute of Texas.

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Handshake antimicrobial stewardship as a model to recognize and prevent diagnostic errors

Diagnosis ◽

10.1515/dx-2020-0032 ◽

2020 ◽

Vol 0 (0) ◽

Author(s):

Justin B. Searns ◽

Manon C. Williams ◽

Christine E. MacBrayne ◽

Ann L. Wirtz ◽

Jan E. Leonard ◽

...

Keyword(s):

Antimicrobial Stewardship ◽

Interrater Reliability ◽

Diagnostic Errors ◽

Diagnostic Error ◽

Primary Treatment ◽

Treatment Team ◽

Children's Hospital ◽

Children’S Hospital ◽

The Impact ◽

Made In

AbstractObjectivesFew studies describe the impact of antimicrobial stewardship programs (ASPs) on recognizing and preventing diagnostic errors. Handshake stewardship (HS-ASP) is a novel ASP model that prospectively reviews hospital-wide antimicrobial usage with recommendations made in person to treatment teams. The purpose of this study was to determine if HS-ASP could identify and intervene on potential diagnostic errors for children hospitalized at a quaternary care children’s hospital.MethodsPreviously self-identified “Great Catch” (GC) interventions by the Children’s Hospital Colorado HS-ASP team from 10/2014 through 5/2018 were retrospectively reviewed. Each GC was categorized based on the types of recommendations from HS-ASP, including if any diagnostic recommendations were made to the treatment team. Each GC was independently scored using the “Safer Dx Instrument” to determine presence of diagnostic error based on a previously determined cut-off score of ≤1.50. Interrater reliability for the instrument was measured using a randomized subset of one third of GCs.ResultsDuring the study period, there were 162 GC interventions. Of these, 65 (40%) included diagnostic recommendations by HS-ASP and 19 (12%) had a Safer Dx Score of ≤1.50, (Κ=0.44; moderate agreement). Of those GCs associated with diagnostic errors, the HS-ASP team made a diagnostic recommendation to the primary treatment team 95% of the time.ConclusionsHandshake stewardship has the potential to identify and intervene on diagnostic errors for hospitalized children.

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Data warehousing management issues in online recruiting

Human Systems Management ◽

10.3233/hsm-2002-21101 ◽

2002 ◽

Vol 21 (1) ◽

pp. 1-8

Author(s):

Binshan Lin ◽

Victoria S. Stasinskaya

Keyword(s):

Personal Data ◽

Employment Opportunities ◽

Missed Opportunities ◽

Employment Services ◽

Online Recruiting ◽

Large Databases ◽

Job Candidates ◽

Management Issues ◽

Analyze Data

Online recruiting is becoming one of the major trends in Human Resource Management. Managers are capable of finding quickly and efficiently qualified candidates to fill variety of professional positions within United States and overseas. Varieties of websites were created online to store resumes for the employer's search in the form of database warehouses and datamarts. Datamarts target specific segments of the employment opportunities. Managers run queries to search and analyze data abstracted from these large databases. Major issues for managers in using online recruitment present accuracy, verifiability, and accountability of the data selected. An obstacle for potential employees using online employment services is the privacy of the data submitted by them from current employers and other websites collecting their personal data without consent for marketing purposes. Another issue in online employment databases remains inefficiencies in the ways the data is be retrieved, stored and analyzed. The lack of personal touch during online employment limits communicational flow between potential employees and the employer, leading to the frustrations of the job candidates and missed opportunities on the behalf of the employers. A follow-up service from the site can serve as a communicational link in the process.

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Use of patient complaints to identify diagnosis-related safety concerns: a mixed-method evaluation

BMJ Quality & Safety ◽

10.1136/bmjqs-2020-011593 ◽

2021 ◽

pp. bmjqs-2020-011593

Author(s):

Traber D Giardina ◽

Saritha Korukonda ◽

Umber Shahid ◽

Viralkumar Vaghani ◽

Divvy K Upadhyay ◽

...

Keyword(s):

Medical Record ◽

Clinical Care ◽

Diagnostic Testing ◽

Diagnostic Errors ◽

Diagnostic Error ◽

Diagnostic Process ◽

Healthcare Organisation ◽

Safety Concerns ◽

Patient Complaints ◽

Malpractice Claims

BackgroundPatient complaints are associated with adverse events and malpractice claims but underused in patient safety improvement.ObjectiveTo systematically evaluate the use of patient complaint data to identify safety concerns related to diagnosis as an initial step to using this information to facilitate learning and improvement.MethodsWe reviewed patient complaints submitted to Geisinger, a large healthcare organisation in the USA, from August to December 2017 (cohort 1) and January to June 2018 (cohort 2). We selected complaints more likely to be associated with diagnostic concerns in Geisinger’s existing complaint taxonomy. Investigators reviewed all complaint summaries and identified cases as ‘concerning’ for diagnostic error using the National Academy of Medicine’s definition of diagnostic error. For all ‘concerning’ cases, a clinician-reviewer evaluated the associated investigation report and the patient’s medical record to identify any missed opportunities in making a correct or timely diagnosis. In cohort 2, we selected a 10% sample of ‘concerning’ cases to test this smaller pragmatic sample as a proof of concept for future organisational monitoring.ResultsIn cohort 1, we reviewed 1865 complaint summaries and identified 177 (9.5%) concerning reports. Review and analysis identified 39 diagnostic errors. Most were categorised as ‘Clinical Care issues’ (27, 69.2%), defined as concerns/questions related to the care that is provided by clinicians in any setting. In cohort 2, we reviewed 2423 patient complaint summaries and identified 310 (12.8%) concerning reports. The 10% sample (n=31 cases) contained five diagnostic errors. Qualitative analysis of cohort 1 cases identified concerns about return visits for persistent and/or worsening symptoms, interpersonal issues and diagnostic testing.ConclusionsAnalysis of patient complaint data and corresponding medical record review identifies patterns of failures in the diagnostic process reported by patients and families. Health systems could systematically analyse available data on patient complaints to monitor diagnostic safety concerns and identify opportunities for learning and improvement.

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Lessons in clinical reasoning – pitfalls, myths, and pearls: the contribution of faulty data gathering and synthesis to diagnostic error

Diagnosis ◽

10.1515/dx-2019-0108 ◽

2021 ◽

Vol 0 (0) ◽

Author(s):

Martin A. Schaller-Paule ◽

Helmuth Steinmetz ◽

Friederike S. Vollmer ◽

Melissa Plesac ◽

Felix Wicke ◽

...

Keyword(s):

Patient Safety ◽

Clinical Reasoning ◽

Data Gathering ◽

Diagnostic Errors ◽

Diagnostic Error ◽

Care Physician ◽

Diagnostic Process ◽

Myasthenic Crisis ◽

Hospital Organization ◽

Substantial Impact

Abstract Objectives Errors in clinical reasoning are a major factor for delayed or flawed diagnoses and put patient safety at risk. The diagnostic process is highly dependent on dynamic team factors, local hospital organization structure and culture, and cognitive factors. In everyday decision-making, physicians engage that challenge partly by relying on heuristics – subconscious mental short-cuts that are based on intuition and experience. Without structural corrective mechanisms, clinical judgement under time pressure creates space for harms resulting from systems and cognitive errors. Based on a case-example, we outline different pitfalls and provide strategies aimed at reducing diagnostic errors in health care. Case presentation A 67-year-old male patient was referred to the neurology department by his primary-care physician with the diagnosis of exacerbation of known myasthenia gravis. He reported shortness of breath and generalized weakness, but no other symptoms. Diagnosis of respiratory distress due to a myasthenic crisis was made and immunosuppressive therapy and pyridostigmine were given and plasmapheresis was performed without clinical improvement. Two weeks into the hospital stay, the patient’s dyspnea worsened. A CT scan revealed extensive segmental and subsegmental pulmonary emboli. Conclusions Faulty data gathering and flawed data synthesis are major drivers of diagnostic errors. While there is limited evidence for individual debiasing strategies, improving team factors and structural conditions can have substantial impact on the extent of diagnostic errors. Healthcare organizations should provide the structural supports to address errors and promote a constructive culture of patient safety.

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Lessons in clinical reasoning ‒ pitfalls, myths and pearls: a case of recurrent pancreatitis

Diagnosis ◽

10.1515/dx-2021-0035 ◽

2021 ◽

Vol 0 (0) ◽

Author(s):

Vita Jaspan ◽

Verity Schaye ◽

Andrew S. Parsons ◽

David Kudlowitz

Keyword(s):

Acute Pancreatitis ◽

Clinical Reasoning ◽

Cognitive Biases ◽

Diagnostic Errors ◽

Diagnostic Error ◽

First Episode ◽

Gut Flora ◽

Case Presentation ◽

Early Hypothesis ◽

Elevated Transaminases

Abstract Objectives Cognitive biases can result in clinical reasoning failures that can lead to diagnostic errors. Autobrewery syndrome is a rare, but likely underdiagnosed, condition in which gut flora ferment glucose, producing ethanol. It most frequently presents with unexplained episodes of inebriation, though more case studies are necessary to better characterize the syndrome. Case presentation This is a case of a 41-year old male with a past medical history notable only for frequent sinus infections, who presented with recurrent episodes of acute pancreatitis. In the week prior to his first episode of pancreatitis, he consumed four beers, an increase from his baseline of 1–2 drinks per month. At home, he had several episodes of confusion, which he attributed to fatigue. He underwent laparoscopic cholecystectomy and testing for genetic and autoimmune causes of pancreatitis, which were non-revealing. He was hospitalized 10 more times during that 9-month period for acute pancreatitis with elevated transaminases. During these admissions, he had elevated triglycerides requiring an insulin drip and elevated alcohol level despite abstaining from alcohol for the prior eight months. His alcohol level increased after consumption of complex carbohydrates, confirming the diagnosis of autobrewery syndrome. Conclusions Through integrated commentary on the diagnostic reasoning process, this case underscores how overconfidence can lead to premature closure and anchoring resulting in diagnostic error. Using a metacognitive overview, case discussants describe the importance of structured reflection and a standardized approach to early hypothesis generation to navigate these cognitive biases.

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