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

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

International Journal of Emergency Medicine ◽

10.1186/s12245-021-00365-6 ◽

2021 ◽

Vol 14 (1) ◽

Author(s):

Azumi Kawabata ◽

Hiraku Funakoshi ◽

Joji Ito ◽

Takushi Santanda ◽

Yasuhiro Norisue ◽

...

Keyword(s):

Emergency Department ◽

Mitral Regurgitation ◽

Correct Diagnosis ◽

Diagnostic Delay ◽

Diagnostic Errors ◽

Diagnostic Error ◽

Delay In Diagnosis ◽

Increased Risk ◽

Anchoring Bias ◽

Acute Mitral Regurgitation

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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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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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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Diagnostic errors are common in acute pediatric respiratory disease: a prospective, single-blinded multicentre diagnostic accuracy study in Australian Emergency Departments

10.1101/2021.07.06.21259221 ◽

2021 ◽

Author(s):

Paul Porter ◽

Joanna Brisbane ◽

Jamie Tan ◽

Natasha Bear ◽

Jennifer Choveaux ◽

...

Keyword(s):

Emergency Department ◽

Emergency Departments ◽

Expert Panel ◽

Diagnostic Errors ◽

Diagnostic Error ◽

Pediatric Emergency ◽

Diagnostic Accuracy Study ◽

Respiratory Tract Disease ◽

Accuracy Study ◽

Tract Disease

Background Diagnostic errors are a global health priority and a common cause of preventable harm. There is limited data available for the prevalence of misdiagnosis in pediatric acute-care settings. Respiratory illnesses, which are particularly challenging to diagnose, are the most frequent reason for presentation to pediatric emergency departments. Objective To determine the diagnostic error rate of acute childhood respiratory diseases in emergency departments. Methods Prospective, multicenter, single-blinded, diagnostic accuracy study in two well-resourced pediatric emergency departments in a large Australian city. Between September 2016 and August 2018, a convenience sample of children aged 29 days to 12 years who presented with respiratory symptoms was enrolled. The emergency department discharge diagnoses were reported by clinicians based upon standard clinical diagnostic definitions. These diagnoses were compared against consensus diagnoses given by an expert panel of pediatric specialists using standardized disease definitions after they reviewed all medical records. Results For 620 participants, the positive and negative percent agreement (%, [95% CI]) of the emergency department compared with the expert panel diagnoses were generally poor: isolated upper respiratory tract disease (61.4 [51.2, 70.9], 90.9 [88.1, 93.3]), croup (75.6 [64.9, 84.4], 97.9 [96.2, 98.9]), lower respiratory tract disease (86.4 [83.1, 89.6], 92.9 [87.7, 96.4]), bronchiolitis (66.9 [58.6, 74.5], 94.3 [80.8, 99.3]), asthma/reactive airway disease (91.0 [85.8, 94.8], 93.0 [90.1, 95.3]), clinical pneumonia (62.9 [49.7, 74.8], 95.0 [92.8, 96.7]), focal (consolidative) pneumonia (54.8 [38.7, 70.2], 86.2 [79.3, 91.5]). Only 59% of chest x-rays with consolidation were correctly identified. Between 6.9% and 14.5% of children were inappropriately prescribed based on their eventual diagnosis. Conclusion In well-resourced emergency departments, we have identified a previously unrecognized high diagnostic error rate for acute childhood respiratory disorders, particularly in pneumonia and bronchiolitis. These errors lead to the potential of avoidable harm and the administration of inappropriate treatment.

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Comparison of laparoscopic and hand-assisted laparoscopic nephrectomy for inflammatory renal disease: which is the preferred approach?

Therapeutic Advances in Urology ◽

10.1177/1756287220984046 ◽

2021 ◽

Vol 13 ◽

pp. 175628722098404

Author(s):

Xudong Guo ◽

Hanbo Wang ◽

Yuzhu Xiang ◽

Xunbo Jin ◽

Shaobo Jiang

Keyword(s):

Logistic Regression ◽

Renal Disease ◽

Complication Rate ◽

Adverse Outcomes ◽

Laparoscopic Nephrectomy ◽

Multivariable Logistic Regression Analysis ◽

Invasive Approach ◽

Intraoperative Complication ◽

Multivariable Logistic Regression ◽

Significant Difference

Aims: Management of inflammatory renal disease (IRD) can still be technically challenging for laparoscopic procedures. The aim of the present study was to compare the safety and feasibility of laparoscopic and hand-assisted laparoscopic nephrectomy in patients with IRD. Patients and methods: We retrospectively analyzed the data of 107 patients who underwent laparoscopic nephrectomy (LN) and hand-assisted laparoscopic nephrectomy (HALN) for IRD from January 2008 to March 2020, including pyonephrosis, renal tuberculosis, hydronephrosis, and xanthogranulomatous pyelonephritis. Patient demographics, operative outcomes, and postoperative recovery and complications were compared between the LN and HALN groups. Multivariable logistic regression analysis was conducted to identify the independent predictors of adverse outcomes. Results: Fifty-five subjects in the LN group and 52 subjects in the HALN group were enrolled in this study. In the LN group, laparoscopic nephrectomy was successfully performed in 50 patients (90.9%), while four (7.3%) patients were converted to HALN and one (1.8%) case was converted to open procedure. In HALN group, operations were completed in 51 (98.1%) patients and conversion to open surgery was necessary in one patient (1.9%). The LN group had a shorter median incision length (5 cm versus 7 cm, p < 0.01) but a longer median operative duration (140 min versus 105 min, p < 0.01) than the HALN group. There was no significant difference in blood loss, intraoperative complication rate, postoperative complication rate, recovery of bowel function, and hospital stay between the two groups. Multivariable logistic regression revealed that severe perinephric adhesions was an independent predictor of adverse outcomes. Conclusion: Both LN and HALN appear to be safe and feasible for IRD. As a still minimally invasive approach, HALN provided an alternative to IRD or when conversion was needed in LN.

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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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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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Mortality risk prediction in lupus patients complicated with invasive infection in the emergency department: LUPHAS score

Therapeutic Advances in Musculoskeletal Disease ◽

10.1177/1759720x19885559 ◽

2019 ◽

Vol 11 ◽

pp. 1759720X1988555 ◽

Cited By ~ 1

Author(s):

Wanlong Wu ◽

Jun Ma ◽

Yuhong Zhou ◽

Chao Tang ◽

Feng Zhao ◽

...

Keyword(s):

Emergency Department ◽

Prediction Model ◽

Risk Score ◽

Roc Curve ◽

Curve Analysis ◽

Multivariable Logistic Regression Analysis ◽

Invasive Infection ◽

Roc Curve Analysis ◽

All Cause Mortality ◽

Qsofa Score

Background: Infection remains a major cause of morbidity and mortality in patients with systemic lupus erythematosus (SLE). This study aimed to establish a clinical prediction model for the 3-month all-cause mortality of invasive infection events in patients with SLE in the emergency department. Methods: SLE patients complicated with invasive infection admitted into the emergency department were included in this study. Patient’s demographic, clinical, and laboratory characteristics on admission were retrospectively collected as baseline data and compared between the deceased and the survivors. Independent predictors were identified by multivariable logistic regression analysis. A prediction model for all-cause mortality was established and evaluated by receiver operating characteristic (ROC) curve analysis. Results: A total of 130 eligible patients were collected with a cumulative 38.5% 3-month mortality. Lymphocyte count <800/ul, urea >7.6mmol/l, maximum prednisone dose in the past ⩾60 mg/d, quick Sequential Organ Failure Assessment (qSOFA) score, and age at baseline were independent predictors for all-cause mortality (LUPHAS). In contrast, a history of hydroxychloroquine use was protective. In a combined, odds ratio-weighted LUPHAS scoring system (score 3–22), patients were categorized to three groups: low-risk (score 3–9), medium-risk (score 10–15), and high-risk (score 16–22), with mortalities of 4.9% (2/41), 45.9% (28/61), and 78.3% (18/23) respectively. ROC curve analysis indicated that a LUPHAS score could effectively predict all-cause mortality [area under the curve (AUC) = 0.86, CI 95% 0.79–0.92]. In addition, LUPHAS score performed better than the qSOFA score alone (AUC = 0.69, CI 95% 0.59–0.78), or CURB-65 score (AUC = 0.69, CI 95% 0.59–0.80) in the subgroup of lung infections ( n = 108). Conclusions: Based on a large emergency cohort of lupus patients complicated with invasive infection, the LUPHAS score was established to predict the short-term all-cause mortality, which could be a promising applicable tool for risk stratification in clinical practice.

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