Clinical criteria to screen for inpatient diagnostic errors: a scoping review

AbstractDiagnostic errors are common and costly, but difficult to detect. “Trigger” tools have promise to facilitate detection, but have not been applied specifically for inpatient diagnostic error. We performed a scoping review to collate all individual “trigger” criteria that have been developed or validated that may indicate that an inpatient diagnostic error has occurred. We searched three databases and screened 8568 titles and abstracts to ultimately include 33 articles. We also developed a conceptual framework of diagnostic error outcomes using real clinical scenarios, and used it to categorize the extracted criteria. Of the multiple criteria we found related to inpatient diagnostic error and amenable to automated detection, the most common were death, transfer to a higher level of care, arrest or “code”, and prolonged length of hospital stay. Several others, such as abrupt stoppage of multiple medications or change in procedure, may also be useful. Validation for general adverse event detection was done in 15 studies, but only one performed validation for diagnostic error specifically. Automated detection was used in only two studies. These criteria may be useful for developing diagnostic error detection tools.

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Antimicrobial Use in COVID-19 Patients in the First Phase of the SARS-CoV-2 Pandemic: A Scoping Review

Antibiotics ◽

10.3390/antibiotics10060745 ◽

2021 ◽

Vol 10 (6) ◽

pp. 745

Author(s):

Wenjuan Cong ◽

Ak Narayan Poudel ◽

Nour Alhusein ◽

Hexing Wang ◽

Guiqing Yao ◽

...

Keyword(s):

Critical Illness ◽

Scoping Review ◽

Clinical Evidence ◽

Length Of Hospital Stay ◽

Severity Of Illness ◽

Antibiotic Prescribing ◽

Antimicrobial Use ◽

Clinical Scenarios ◽

Scoping Reviews ◽

The Impact

This scoping review provides new evidence on the prevalence and patterns of global antimicrobial use in the treatment of COVID-19 patients; identifies the most commonly used antibiotics and clinical scenarios associated with antibiotic prescribing in the first phase of the pandemic; and explores the impact of documented antibiotic prescribing on treatment outcomes in COVID-19 patients. The review complies with PRISMA guidelines for Scoping Reviews and the protocol is registered with the Open Science Framework. In the first six months of the pandemic, there was a similar mean antibiotic prescribing rate between patients with severe or critical illness (75.4%) and patients with mild or moderate illness (75.1%). The proportion of patients prescribed antibiotics without clinical justification was 51.5% vs. 41.9% for patients with mild or moderate illness and those with severe or critical illness. Comparison of patients who were provided antibiotics with a clinical justification with those who were given antibiotics without clinical justification showed lower mortality rates (9.5% vs. 13.1%), higher discharge rates (80.9% vs. 69.3%), and shorter length of hospital stay (9.3 days vs. 12.2 days). In the first 6 months of the pandemic, antibiotics were prescribed for COVID-19 patients regardless of severity of illness. A large proportion of antibiotic prescribing for mild and moderate COVID-19 patients did not have clinical evidence of a bacterial co-infection. Antibiotics may not be beneficial to COVID-19 patients without clinical evidence of a bacterial co-infection.

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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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Analysis of machete cut fractures in Nigerian civilian trauma setting

Scientific Reports ◽

10.1038/s41598-020-79981-w ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Njoku Isaac Omoke ◽

Omolade Ayoola Lasebikan ◽

Francis Ndubuisi Ahaotu ◽

Ugochukwu Uzodimma Nnadozie ◽

Gregory Chinedu Nwigwe

Keyword(s):

Hemorrhagic Shock ◽

Hospital Care ◽

Case Fatality ◽

Length Of Hospital Stay ◽

Accidental Injury ◽

Early Presentation ◽

Female Ratio ◽

Prolonged Length ◽

Civilian Trauma ◽

One Year

AbstractMachete cut fracture is an important component of morbidity associated with machete injuries although it is under reported. This was a retrospective study to assess machete cut fractures in patients seen in Federal Teaching Hospital Abakaliki and National Orthopaedic Hospital Enugu from 2009 to 2018. There were 91 patients with 154 fractures, male- to- female ratio was 10:1 and mean age was 31.6 ± 14.6 years. The aetiological factors were assault (57, 62.6%), armed robbery (29, 31.9%) and accidental injury (5, 5.5%). The three top bones involved were ulna, metacarpal and finger-phalanx. Fracture was communited in (17, 11.0%), and Gustilo Anderson grade IIIC in (22, 14.3%). Injury to hospital arrival interval later than 6 h was common and correlated with prolonged length of hospital stay (p < 0.001). Anaemia, wound infection and hemorrhagic shock were the three top complications. Nine (5.8%) fractures ended in extremity amputation. Eleven (12.1%) patients left against medical advice, and 5 (5.5%) were transferred. Normal union in 98.3% of the fractures treated and followed up for a minimum of one year. Case fatality rate was 2.2%; none of the patient that died had pre hospital care, and hemorrhagic shock accounted for all the mortality. These call for appropriate injury preventive mechanisms, and improved rates of early presentation of patients to hospital, and pre hospital care.

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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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Cardiotoxicity Associated with Anti-CD19 Chimeric Antigen Receptor T-Cell (CAR-T) Therapy: Recognition, Risk Factors, and Management

Diseases ◽

10.3390/diseases9010020 ◽

2021 ◽

Vol 9 (1) ◽

pp. 20

Author(s):

Ethan A. Burns ◽

Cesar Gentille ◽

Barry Trachtenberg ◽

Sai Ravi Pingali ◽

Kartik Anand

Keyword(s):

Risk Factors ◽

Chimeric Antigen Receptor ◽

Antigen Receptor ◽

Length Of Hospital Stay ◽

Clinical Trial Data ◽

Cardiac Events ◽

Prolonged Length ◽

Non Hodgkin Lymphoma ◽

Car T ◽

Potential Risk Factors

Chimeric antigen receptor T-cells (CAR-T) are improving outcomes in pediatric and adult patients with relapsed or refractory B-cell acute lymphoblastic leukemias and subtypes of non-Hodgkin Lymphoma. As this treatment is being increasingly utilized, a better understanding of the unique toxicities associated with this therapy is warranted. While there is growing knowledge on the diagnosis and treatment of cytokine release syndrome (CRS), relatively little is known about the associated cardiac events that occur with CRS that may result in prolonged length of hospital stay, admission to the intensive care unit for pressor support, or cardiac death. This review focuses on the various manifestations of cardiotoxicity, potential risk factors, real world and clinical trial data on prevalence of reported cardiotoxicity events, and treatment recommendations.

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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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Checklists to prevent diagnostic errors: a pilot randomized controlled trial

Diagnosis ◽

10.1515/dx-2015-0008 ◽

2015 ◽

Vol 2 (3) ◽

pp. 163-169 ◽

Cited By ~ 8

Author(s):

John W. Ely ◽

Mark A. Graber

Keyword(s):

Primary Care ◽

Usual Care ◽

Error Rate ◽

Primary Care Physicians ◽

Diagnostic Errors ◽

Diagnostic Error ◽

Diagnostic Process ◽

Emergency Physicians ◽

Mean Error ◽

Premature Closure

AbstractMany diagnostic errors are caused by premature closure of the diagnostic process. To help prevent premature closure, we developed checklists that prompt physicians to consider all reasonable diagnoses for symptoms that commonly present in primary care.We enrolled 14 primary care physicians and 100 patients in a randomized clinical trial. The study took place in an emergency department (5 physicians) and a same-day access clinic (9 physicians). The physicians were randomized to usual care vs. diagnostic checklist. After completing the history and physical exam, checklist physicians read aloud a differential diagnosis checklist for the chief complaint. The primary outcome was diagnostic error, which was defined as a discrepancy between the diagnosis documented at the acute visit and the diagnosis based on a 1-month follow-up phone call and record review.There were 17 diagnostic errors. The mean error rate among the seven checklist physicians was not significantly different from the rate among the seven usual-care physicians (11.2% vs. 17.8%; p=0.46). In a post-hoc subgroup analysis, emergency physicians in the checklist group had a lower mean error rate than emergency physicians in the usual-care group (19.1% vs. 45.0%; p=0.04). Checklist physicians considered more diagnoses than usual-care physicians during the patient encounters (6.5 diagnoses [SD 4.2] vs. 3.4 diagnoses [SD 2.0], p<0.001).Checklists did not improve the diagnostic error rate in this study. However further development and testing of checklists in larger studies may be warranted.

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Classification of Error in Abdominal Imaging: Pearls and Pitfalls for Radiologists

Canadian Association of Radiologists Journal ◽

10.1016/j.carj.2018.06.006 ◽

2018 ◽

Vol 69 (4) ◽

pp. 409-416 ◽

Cited By ~ 1

Author(s):

Csilla Egri ◽

Kathryn E. Darras ◽

Elena P. Scali ◽

Alison C. Harris

Keyword(s):

Peer Review ◽

Diagnostic Errors ◽

Diagnostic Error ◽

Abdominal Imaging ◽

Patient Harm ◽

Contributing Factors ◽

Abdominal Radiology ◽

Pictorial Review ◽

Classification Of Error

Peer review for radiologists plays an important role in identifying contributing factors that can lead to diagnostic errors and patient harm. It is essential that all radiologists be aware of the multifactorial causes of diagnostic error in radiology and the methods available to reduce it. This pictorial review provides readers with an overview of common errors that occur in abdominal radiology and strategies to reduce them. This review aims to make readers more aware of pitfalls in abdominal imaging so that these errors can be avoided in the future. This essay also provides a systematic approach to classifying abdominal imaging errors that will be of value to all radiologists participating in peer review.

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Ordering a Normal Diet at the End of Surgery—Justified or Overhasty?

Nutrients ◽

10.3390/nu10111758 ◽

2018 ◽

Vol 10 (11) ◽

pp. 1758 ◽

Cited By ~ 2

Author(s):

Fabian Grass ◽

Martin Hübner ◽

Jenna Lovely ◽

Jacopo Crippa ◽

Kellie Mathis ◽

...

Keyword(s):

Enhanced Recovery ◽

Length Of Hospital Stay ◽

Outcome Data ◽

Normal Diet ◽

Oral Feeding ◽

Prolonged Length ◽

Early Oral Feeding ◽

American Society ◽

Independent Decision ◽

Recovery Pathways

Early re-alimentation is advocated by enhanced recovery pathways (ERP). This study aimed to assess compliance to ERP-set early re-alimentation policy and to compare outcomes of early fed patients and patients in whom early feeding was withhold due to the independent decision making of the surgeon. For this purpose, demographic, surgical and outcome data of all consecutive elective colorectal surgical procedures (2011–2016) were retrieved from a prospectively maintained institutional ERP database. The primary endpoint was postoperative ileus (POI). Surgical 30-day outcome and length of stay were compared between patients undergoing the pathway-intended early re-alimentation pattern and patients in whom early re-alimentation was not compliant. Out of the 7103 patients included, 1241 (17.4%) were not compliant with ERP re-alimentation. Patients with delayed re-alimentation presented with more postoperative complications (37 vs. 21%, p < 0.001) and a prolonged length of hospital stay (8 ± 7 vs. 5 ± 4 days, p < 0.001). While male gender (odds ratio (OR) 1.24; 95% confidence interval (CI) 1.04–1.32), fluid overload (OR 1.38; 95% CI 1.16–1.65) and high American Society of Anaesthesiologists (ASA) score (OR 1.51; 95% CI 1.27–1.8) were independent risk factors for POI, laparoscopy (OR 0.51; 95% CI 0.38–0.68) and ERP compliant diet (OR 0.46; 95% CI 0.36–0.6) were both protective. Hence, this study provides further evidence of the beneficial effect of early oral feeding after colorectal surgery.

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