Diagnostic delay of acute mitral regurgitation during the coronavirus disease 2019 pandemic: a case report

Abstract Background Diagnostic errors or delays can cause serious consequences for patient safety, especially in the emergency department. Anchoring bias is one of the major factors leading to diagnostic error. During the coronavirus disease 2019 (COVID-19) pandemic, the high probability of COVID-19 in febrile patients could be a major cause of anchoring bias leading to diagnostic error. In addition, certain evaluations such as auscultation are difficult to perform on a casual basis due to the increased risk of contact infection, which lead to inadequate assessment of the patients with valvular disease. Acute mitral regurgitation (MR) could be a fatal disease in the emergency department, especially if there is a diagnostic error or delay in diagnosis. It is often reported that diagnosis can be difficult even though there is no treatment other than emergent surgery. The diagnosis of acute MR has become more difficult because coronavirus disease 2019 (COVID-19) pandemic could affect our daily practice especially in febrile patients. We report a case of a diagnostic delay of a febrile patient because of anchoring bias during the COVID-19 pandemic. Case presentation A 45-year-old man presented to the emergency department complaining of acute dyspnea and fever. Based on vital signs and computed tomography of the chest, acute pneumonia due to COVID-19 was suspected. Auscultation was avoided because of facility rule based on concern of contact infection. After admission to the intensive care unit, Doppler echocardiography revealed acute mitral regurgitation, and transesophageal echocardiography revealed mitral valve tendon rupture. After confirming the negative result for the polymerase chain reaction of severe acute respiratory syndrome coronavirus 2, mitral valvuloplasty was performed on the third day after admission. The patient was discharged 14 days after admission without complications. Conclusions In COVID-19 pandemic, anchoring bias suspecting COVID-19 among febrile patients becomes a strong heuristic factor. A thorough history and physical examination is still important in febrile patients presenting with dyspnea to ensure the correct diagnosis of acute mitral regurgitation.

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Improving Team-Based Decision Making Using Data Analytics and Informatics: Protocol for a Collaborative Decision Support Design

JMIR Research Protocols ◽

10.2196/16047 ◽

2019 ◽

Vol 8 (11) ◽

pp. e16047 ◽

Cited By ~ 4

Author(s):

Don Roosan ◽

Anandi V Law ◽

Mazharul Karim ◽

Moom Roosan

Keyword(s):

Decision Making ◽

Data Analytics ◽

Correct Diagnosis ◽

Diagnostic Errors ◽

Diagnostic Error ◽

Positive Direction ◽

Team Members ◽

Diagnostic Decision ◽

Diagnostic Decision Making ◽

Collaborative Decision

Background According to the September 2015 Institute of Medicine report, Improving Diagnosis in Health Care, each of us is likely to experience one diagnostic error in our lifetime, often with devastating consequences. Traditionally, diagnostic decision making has been the sole responsibility of an individual clinician. However, diagnosis involves an interaction among interprofessional team members with different training, skills, cultures, knowledge, and backgrounds. Moreover, diagnostic error is prevalent in the interruption-prone environment, such as the emergency department, where the loss of information may hinder a correct diagnosis. Objective The overall purpose of this protocol is to improve team-based diagnostic decision making by focusing on data analytics and informatics tools that improve collective information management. Methods To achieve this goal, we will identify the factors contributing to failures in team-based diagnostic decision making (aim 1), understand the barriers of using current health information technology tools for team collaboration (aim 2), and develop and evaluate a collaborative decision-making prototype that can improve team-based diagnostic decision making (aim 3). Results Between 2019 to 2020, we are collecting data for this study. The results are anticipated to be published between 2020 and 2021. Conclusions The results from this study can shed light on improving diagnostic decision making by incorporating diagnostics rationale from team members. We believe a positive direction to move forward in solving diagnostic errors is by incorporating all team members, and using informatics. International Registered Report Identifier (IRRID) DERR1-10.2196/16047

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Impact of diagnostic errors on adverse outcomes: learning from emergency department revisits with repeat CT or MRI

Insights into Imaging ◽

10.1186/s13244-021-01108-0 ◽

2021 ◽

Vol 12 (1) ◽

Author(s):

Yura Ahn ◽

Gil-Sun Hong ◽

Kye Jin Park ◽

Choong Wook Lee ◽

Ju Hee Lee ◽

...

Keyword(s):

Emergency Department ◽

Diagnostic Errors ◽

Diagnostic Error ◽

Adverse Outcomes ◽

Multivariable Logistic Regression Analysis ◽

Imaging Studies ◽

Neurologic Diseases ◽

Logistic Analysis ◽

Digestive Diseases ◽

Repeat Imaging

Abstract Background To investigate diagnostic errors and their association with adverse outcomes (AOs) during patient revisits with repeat imaging (RVRIs) in the emergency department (ED). Results Diagnostic errors stemming from index imaging studies and AOs within 30 days in 1054 RVRIs (≤ 7 days) from 2005 to 2015 were retrospectively analyzed according to revisit timing (early [≤ 72 h] or late [> 72 h to 7 days] RVRIs). Risk factors for AOs were assessed using multivariable logistic analysis. The AO rate in the diagnostic error group was significantly higher than that in the non-error group (33.3% [77 of 231] vs. 14.8% [122 of 823], p < .001). The AO rate was the highest in early revisits within 72 h if diagnostic errors occurred (36.2%, 54 of 149). The most common diseases associated with diagnostic errors were digestive diseases in the radiologic misdiagnosis category (47.5%, 28 of 59) and neurologic diseases in the delayed radiology reporting time (46.8%, 29 of 62) and clinician error (27.3%, 30 of 110) categories. In the matched set of the AO and non-AO groups, multivariable logistic regression analysis revealed that the following diagnostic errors contributed to AO occurrence: radiologic error (odds ratio [OR] 3.56; p < .001) in total RVRIs, radiologic error (OR 3.70; p = .001) and clinician error (OR 4.82; p = .03) in early RVRIs, and radiologic error (OR 3.36; p = .02) in late RVRIs. Conclusion Diagnostic errors in index imaging studies are strongly associated with high AO rates in RVRIs in the ED.

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Missed diagnoses of acute myocardial infarction in the emergency department: variation by patient and facility characteristics

Diagnosis ◽

10.1515/dx-2014-0053 ◽

2015 ◽

Vol 2 (1) ◽

pp. 29-40 ◽

Cited By ~ 14

Author(s):

Ernest Moy ◽

Marguerite Barrett ◽

Rosanna Coffey ◽

Anika L. Hines ◽

David E. Newman-Toker

Keyword(s):

Myocardial Infarction ◽

Acute Myocardial Infarction ◽

Emergency Department ◽

Correct Diagnosis ◽

Diagnostic Errors ◽

Missed Opportunities ◽

Admission Rates ◽

Populations At Risk ◽

Occupancy Rates ◽

Missed Diagnoses

Abstract: An estimated 1.2 million people in the US have an acute myocardial infarction (AMI) each year. An estimated 7% of AMI hospitalizations result in death. Most patients experiencing acute coronary symptoms, such as unstable angina, visit an emergency department (ED). Some patients hospitalized with AMI after a treat-and-release ED visit likely represent missed opportunities for correct diagnosis and treatment. The purpose of the present study is to estimate the frequency of missed AMI or its precursors in the ED by examining use of EDs prior to hospitalization for AMI.: We estimated the rate of probable missed diagnoses in EDs in the week before hospitalization for AMI and examined associated factors. We used Healthcare Cost and Utilization Project State Inpatient Databases and State Emergency Department Databases for 2007 to evaluate missed diagnoses in 111,973 admitted patients aged 18 years and older.: We identified missed diagnoses in the ED for 993 of 112,000 patients (0.9% of all AMI admissions). These patients had visited an ED with chest pain or cardiac conditions, were released, and were subsequently admitted for AMI within 7 days. Higher odds of having missed diagnoses were associated with being younger and of Black race. Hospital teaching status, availability of cardiac catheterization, high ED admission rates, high inpatient occupancy rates, and urban location were associated with lower odds of missed diagnoses.: Administrative data provide robust information that may help EDs identify populations at risk of experiencing a missed diagnosis, address disparities, and reduce diagnostic errors.

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Association between primary care physician diagnostic knowledge and death, hospitalisation and emergency department visits following an outpatient visit at risk for diagnostic error: a retrospective cohort study using medicare claims

BMJ Open ◽

10.1136/bmjopen-2020-041817 ◽

2021 ◽

Vol 11 (4) ◽

pp. e041817

Author(s):

Bradley M Gray ◽

Jonathan L Vandergrift ◽

Rozalina G McCoy ◽

Rebecca S Lipner ◽

Bruce E Landon

Keyword(s):

Primary Care ◽

At Risk ◽

Emergency Department ◽

Cohort Study ◽

Retrospective Cohort Study ◽

Retrospective Cohort ◽

Diagnostic Errors ◽

Diagnostic Error ◽

Adverse Outcomes ◽

Ed Visits

ObjectiveDiagnostic error is a key healthcare concern and can result in substantial morbidity and mortality. Yet no study has investigated the relationship between adverse outcomes resulting from diagnostic errors and one potentially large contributor to these errors: deficiencies in diagnostic knowledge. Our objective was to measure that associations between diagnostic knowledge and adverse outcomes after visits to primary care physicians that were at risk for diagnostic errors.Setting/participants1410 US general internists who recently took their American Board of Internal Medicine Maintenance of Certification (ABIM-IM-MOC) exam treating 42 407 Medicare beneficiaries who experienced 48 632 ‘index’ outpatient visits for new problems at risk for diagnostic error because the presenting problem (eg, dizziness) was related to prespecified diagnostic error sensitive conditions (eg, stroke).Outcome measures90-day risk of all-cause death, and, for outcome conditions related to the index visits diagnosis, emergency department (ED) visits and hospitalisations.DesignUsing retrospective cohort study design, we related physician performance on ABIM-IM-MOC diagnostic exam questions to patient outcomes during the 90-day period following an index visit at risk for diagnostic error after controlling for practice characteristics, patient sociodemographic and baseline clinical characteristics.ResultsRates of 90-day adverse outcomes per 1000 index visits were 7 for death, 11 for hospitalisations and 14 for ED visits. Being seen by a physician in the top versus bottom third of diagnostic knowledge during an index visit for a new problem at risk for diagnostic error was associated with 2.9 fewer all-cause deaths (95% CI −5.0 to −0.7, p=0.008), 4.1 fewer hospitalisations (95% CI −6.9 to −1.2, p=0.006) and 4.9 fewer ED visits (95% CI −8.1% to −1.6%, p=0.003) per 1000 visits.ConclusionHigher diagnostic knowledge was associated with lower risk of adverse outcomes after visits for problems at heightened risk for diagnostic error.

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Feasibility of patient-reported diagnostic errors following emergency department discharge: a pilot study

Diagnosis ◽

10.1515/dx-2020-0014 ◽

2020 ◽

Vol 0 (0) ◽

Cited By ~ 1

Author(s):

Kelly T. Gleason ◽

Susan Peterson ◽

Cheryl R. Dennison Himmelfarb ◽

Mariel Villanueva ◽

Taylor Wynn ◽

...

Keyword(s):

Emergency Department ◽

Diagnostic Errors ◽

Diagnostic Error ◽

Health Concern ◽

Future Research ◽

Clinical Predictors ◽

Patient Reported ◽

Patient’S Experience ◽

Emergency Department Discharge ◽

Measured Response

AbstractObjectivesThe National Academy of Medicine identified diagnostic error as a pressing public health concern and defined failure to effectively communicate the diagnosis to patients as a diagnostic error. Leveraging Patient’s Experience to improve Diagnosis (LEAPED) is a new program for measuring patient-reported diagnostic error. As a first step, we sought to assess the feasibility of using LEAPED after emergency department (ED) discharge.MethodsWe deployed LEAPED using a cohort design at three EDs within one academic health system. We enrolled 59 patients after ED discharge and queried them about their health status and understanding of the explanation for their health problems at 2-weeks, 1-month, and 3-months. We measured response rates and demographic/clinical predictors of patient uptake of LEAPED.ResultsOf those enrolled (n=59), 90% (n=53) responded to the 2-week post-ED discharge questionnaire (1 and 3-month ongoing). Of the six non-responders, one died and three were hospitalized at two weeks. The average age was 50 years (SD 16) and 64% were female; 53% were white and 41% were black. Over a fifth (23%) reported they were not given an explanation of their health problem on leaving the ED, and of those, a fourth (25%) did not have an understanding of what next steps to take after leaving the ED.ConclusionsPatient uptake of LEAPED was high, suggesting that patient-report may be a feasible method of evaluating the effectiveness of diagnostic communication to patients though further testing in a broader patient population is essential. Future research should determine if LEAPED yields important insights into the quality and safety of diagnostic care.

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Use of an Expedited Review Tool to Screen for Prior Diagnostic Error in Emergency Department Patients

Applied Clinical Informatics ◽

10.4338/aci-2015-04-ra-0042 ◽

2015 ◽

Vol 06 (04) ◽

pp. 619-628 ◽

Cited By ~ 3

Author(s):

R. El-Kareh ◽

G. Schiff ◽

J. Hudspeth

Keyword(s):

Emergency Department ◽

Delayed Diagnosis ◽

Diagnostic Errors ◽

Diagnostic Error ◽

Clinical Encounter ◽

Care Quality ◽

Rapid Review ◽

Emergency Department Patients ◽

Missed Diagnoses

Summary Objective: Missed diagnoses are an important area of care quality resulting in significant morbidity and mortality. Determination of rates and causes has been limited by difficulties in screening, including the effort of manual chart review. We developed and tested a semi- automated review tool to expedite screening for diagnostic errors in an electronic health record (EHR). Methods: We retrospectively reviewed patients seen in the emergency department (ED) of a teaching hospital over 31 days, using an automated screen to identify those with a prior in-system visit during the 14 days preceding their ED visit. We collected prior and subsequent notes from the institution’s EHR for these cases, then populated a specially designed relational database enabling rapid comparison of prior visit records to the sentinel ED visit. Each case was assessed for potential missed or delayed diagnosis, and rated by likelihood as “definite, probable, possible, unlikely or none.” Results: A total of 5 066 patient encounters were screened by a clinician using the tool, of which 1 498 (30%) had a clinical encounter within the preceding 14 days. Of these, 37 encounters (2.6% of those reviewed) were “definite” or “probable” missed diagnoses. The rapid review tool took a mean of 1.9 minutes per case for primary review, compared with 11.2 minutes per case for reviews without the automated tool. Conclusions: Diagnostic errors were present in a significant number of cases presenting to the ED after recent healthcare visits. An innovative review tool enabled a substantially increased efficiency in screening for diagnostic errors.

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Using computerized virtual cases to explore diagnostic error in practicing physicians

Diagnosis ◽

10.1515/dx-2017-0044 ◽

2018 ◽

Vol 5 (4) ◽

pp. 229-233

Author(s):

Robert L. Trowbridge ◽

James B. Reilly ◽

Jerome C. Clauser ◽

Steven J. Durning

Keyword(s):

Correct Diagnosis ◽

Diagnostic Errors ◽

Diagnostic Error ◽

Outcome Data ◽

Diagnostic Process ◽

Patient Harm ◽

Physician Performance ◽

Two Phases ◽

Adaptive Nature ◽

Practicing Physicians

Abstract Background Diagnostic errors are a significant cause of patient harm. Cognitive processes often contribute to diagnostic errors but studying and mitigating the effects of these errors is challenging. Computerized virtual patients may provide insight into the diagnostic process without the potential for patient harm, but the feasibility and utility of using such cases in practicing physicians has not been well described. Methods We developed a series of computerized virtual cases depicting common presentations of disease that included contextual factors that could result in diagnostic error. Cases were piloted by practicing physicians in two phases and participant impressions of the case platform and cases were recorded, as was outcome data on physician performance. Results Participants noted significant challenges in using the case platform. Participants specifically struggled with becoming familiar with the platform and adjusting to the non-adaptive and constraining processes of the model. Although participants found the cases to be typical presentations of problems commonly encountered in practice, the correct diagnosis was identified in less than 33% of cases. Conclusions The development of virtual patient cases for use by practicing physicians requires substantial resources and platforms that account for the non-linear and adaptive nature of reasoning in experienced clinicians. Platforms that are without such characteristics may negatively affect diagnostic performance. The novelty of such platforms may also have the potential to increase cognitive load. Nonetheless, virtual cases may have the potential to be a safe and robust means of studying clinical reasoning performance.

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Learning from tragedy: the Julia Berg story

Diagnosis ◽

10.1515/dx-2018-0067 ◽

2018 ◽

Vol 5 (4) ◽

pp. 257-266

Author(s):

Mark L. Graber ◽

Dan Berg ◽

Welcome Jerde ◽

Phillip Kibort ◽

Andrew P.J. Olson ◽

...

Keyword(s):

Cognitive Biases ◽

Correct Diagnosis ◽

Diagnostic Errors ◽

Acalculous Cholecystitis ◽

Liver Function Tests ◽

Diagnostic Error ◽

Epstein Barr Virus Infection ◽

Barr Virus ◽

Presenting Symptoms ◽

Epstein Barr

Abstract This is a case report involving diagnostic errors that resulted in the death of a 15-year-old girl, and commentaries on the case from her parents and involved providers. Julia Berg presented with fatigue, fevers, sore throat and right sided flank pain. Based on a computed tomography (CT) scan that identified an abnormal-appearing gall bladder, and markedly elevated bilirubin and “liver function tests”, she was hospitalized and ultimately underwent surgery for suspected cholecystitis and/or cholangitis. Julia died of unexplained post-operative complications. Her autopsy, and additional testing, suggested that the correct diagnosis was Epstein-Barr virus infection with acalculous cholecystitis. The correct diagnosis might have been considered had more attention been paid to her presenting symptoms, and a striking degree of lymphocytosis that was repeatedly demonstrated. The case illustrates how cognitive “biases” can contribute to harm from diagnostic error. The case has profoundly impacted the involved healthcare organization, and Julia’s parents have become leaders in helping advance awareness and education about diagnostic error and its prevention.

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Identifying trigger concepts to screen emergency department visits for diagnostic errors

Diagnosis ◽

10.1515/dx-2020-0122 ◽

2020 ◽

Vol 0 (0) ◽

Author(s):

Prashant Mahajan ◽

Chih-Wen Pai ◽

Karen S. Cosby ◽

Cynthia J. Mollen ◽

Kathy N. Shaw ◽

...

Keyword(s):

Emergency Department ◽

Expert Panel ◽

Diagnostic Errors ◽

Diagnostic Error ◽

Emergency Department Visits ◽

Therapeutic Interventions ◽

Diagnostic Process ◽

Future Research ◽

Office Referrals ◽

Vital Component

AbstractObjectivesThe diagnostic process is a vital component of safe and effective emergency department (ED) care. There are no standardized methods for identifying or reliably monitoring diagnostic errors in the ED, impeding efforts to enhance diagnostic safety. We sought to identify trigger concepts to screen ED records for diagnostic errors and describe how they can be used as a measurement strategy to identify and reduce preventable diagnostic harm.MethodsWe conducted a literature review and surveyed ED directors to compile a list of potential electronic health record (EHR) trigger (e-triggers) and non-EHR based concepts. We convened a multidisciplinary expert panel to build consensus on trigger concepts to identify and reduce preventable diagnostic harm in the ED.ResultsSix e-trigger and five non-EHR based concepts were selected by the expert panel. E-trigger concepts included: unscheduled ED return to ED resulting in hospital admission, death following ED visit, care escalation, high-risk conditions based on symptom-disease dyads, return visits with new diagnostic/therapeutic interventions, and change of treating service after admission. Non-EHR based signals included: cases from mortality/morbidity conferences, risk management/safety office referrals, ED medical director case referrals, patient complaints, and radiology/laboratory misreads and callbacks. The panel suggested further refinements to aid future research in defining diagnostic error epidemiology in ED settings.ConclusionsWe identified a set of e-trigger concepts and non-EHR based signals that could be developed further to screen ED visits for diagnostic safety events. With additional evaluation, trigger-based methods can be used as tools to monitor and improve ED diagnostic performance.

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Head Computed tomography during emergency department treat-and-release visit for headache is associated with increased risk of subsequent cerebrovascular disease hospitalization

Diagnosis ◽

10.1515/dx-2020-0082 ◽

2020 ◽

Vol 0 (0) ◽

Author(s):

Ava L. Liberman ◽

Cuiling Wang ◽

Benjamin W. Friedman ◽

Shyam Prabhakaran ◽

Charles C. Esenwa ◽

...

Keyword(s):

Computed Tomography ◽

Emergency Department ◽

Propensity Score ◽

Cerebrovascular Disease ◽

Disease Risk ◽

Diagnostic Error ◽

Adult Patients ◽

Increased Risk ◽

Head Computed Tomography ◽

Headache Patients

AbstractObjectivesThe occurrence of head computed tomography (HCT) at emergency department (ED) visit for non-specific neurological symptoms has been associated with increased subsequent stroke risk and may be a marker of diagnostic error. We evaluate whether HCT occurrence among ED headache patients is associated with increased subsequent cerebrovascular disease risk.MethodsWe conducted a retrospective cohort study of consecutive adult patients with headache who were discharged home from the ED (ED treat-and-release visit) at one multicenter institution. Patients with headache were defined as those with primary ICD-9/10-CM discharge diagnoses codes for benign headache from 9/1/2013-9/1/2018. The primary outcome of cerebrovascular disease hospitalization was identified using ICD-9/10-CM codes and confirmed via chart review. We matched headache patients who had a HCT (exposed) to those who did not have a HCT (unexposed) in the ED in a one-to-one fashion using propensity score methods.ResultsAmong the 28,121 adult patients with ED treat-and-release headache visit, 45.6% (n=12,811) underwent HCT. A total of 0.4% (n=111) had a cerebrovascular hospitalization within 365 days of index visit. Using propensity score matching, 80.4% (n=10,296) of exposed patients were matched to unexposed. Exposed patients had increased risk of cerebrovascular hospitalization at 365 days (RR: 1.65: 95% CI: 1.18–2.31) and 180 days (RR: 1.62; 95% CI: 1.06–2.49); risk of cerebrovascular hospitalization was not increased at 90 or 30 days.ConclusionsHaving a HCT performed at ED treat-and-release headache visit is associated with increased risk of subsequent cerebrovascular disease. Future work to improve cerebrovascular disease prevention strategies in this subset of headache patients is warranted.

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