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- Adverse Drug Events (ADE) (2)
- (-) Adverse Events (28)
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- Neonatal Intensive Care Unit (NICU) (1)
- Newborns/Infants (2)
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- Quality of Care (10)
- Sepsis (1)
- Stroke (1)
AHRQ Research Studies
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Research Studies is a compilation of published research articles funded by AHRQ or authored by AHRQ researchers.
Results
1 to 25 of 28 Research Studies DisplayedAuerbach AD, Lee TM, Hubbard CC
Diagnostic errors in hospitalized adults who died or were transferred to intensive care.
The objective of this retrospective cohort study was to determine the prevalence, underlying causes, and harms of diagnostic errors in hospitalized adults who were transferred to an intensive care unit or who died. Data was taken from 29 academic medical centers in the U.S. in a random sample of adults hospitalized with general medical conditions. Errors were found to have contributed to temporary harm, permanent harm, or death in nearly 18% of patients; among patients who died, diagnostic error was judged to have contributed to death in 6.6% of cases. The researchers noted that problems with choosing and interpreting tests and the processes involved with clinician assessment were a high priority for improvement efforts.
AHRQ-funded; HS027369.
Citation: Auerbach AD, Lee TM, Hubbard CC .
Diagnostic errors in hospitalized adults who died or were transferred to intensive care.
JAMA Intern Med 2024 Feb; 184(2):164-73. doi: 10.1001/jamainternmed.2023.7347..
Keywords: Diagnostic Safety and Quality, Medical Errors, Hospitals, Inpatient Care, Quality of Care, Patient Safety, Adverse Events
Dalal AK, Schnipper JL, Raffel K
Identifying and classifying diagnostic errors in acute care across hospitals: early lessons from the Utility of Predictive Systems in Diagnostic Errors (UPSIDE) study.
This paper describes the Utility of Predictive Systems in Diagnostic Errors (UPSIDE) study, whose aim was to define the prevalence and underlying causes of diagnostic errors (DEs) in patients who die in the hospital or are transferred to the intensive care unit (ICU) after the first 48 hours. This study was conducted at 31 hospitals with more than 2500 cases reviewed using electronic health records. The authors identified some insights into key requirements into building a robust DE surveillance program by developing these steps: 1) Develop a shared understanding of what constitutes a diagnostic error; 2) Use validated tools to identify diagnostic errors and classify process failures, but respect your context; 3) Develop a standard approach to using electronic health records for case reviews; 4) Ensure reliability and consistency of the case review process; and 5) Link diagnostic error case reviews to institutional safety programs. They also developed steps to establish a diagnosis error review process at the hospital level with six processes.
AHRQ-funded; HS027369; HS026613.
Citation: Dalal AK, Schnipper JL, Raffel K .
Identifying and classifying diagnostic errors in acute care across hospitals: early lessons from the Utility of Predictive Systems in Diagnostic Errors (UPSIDE) study.
J Hosp Med 2024 Feb; 19(2):140-45. doi: 10.1002/jhm.13136..
Keywords: Diagnostic Safety and Quality, Medical Errors, Adverse Events, Patient Safety, Quality of Care, Hospitals
Newman-Toker DE, Nassery N, Schaffer AC
Burden of serious harms from diagnostic error in the USA.
Americans who experience serious harm from misdiagnosis annually. Serious harm is defined as permanent morbidity or morality. This cross-sectional analysis used nationally representative observational data. The authors estimated annual incident vascular events and infections from 21.5 million (M) sampled US hospital discharges (2012-2014). US-based cancer registries were used to find annual new cancers. They derived diagnostic errors and serious harms by multiplying by literature-based rates for disease-specific incidences for 15 major vascular events, infections and cancers ('Big Three' categories). Extrapolating to all diseases (including non-'Big Three' dangerous disease categories), they estimated total serious harms annually in the USA to be 795,000 (plausible range 598,000-1,023,000). Using more conservative assumptions they estimated 549,000 serious harms. These results were compatible with setting-specific serious harm estimates from inpatient, emergency department and ambulatory care. Fifteen dangerous diseases accounted for 50.7% of total serious harms and the top 5 (stroke, sepsis, pneumonia, venous thromboembolism and lung cancer) accounted for 38.7%.
AHRQ-funded; HS027614; HS029350.
Citation: Newman-Toker DE, Nassery N, Schaffer AC .
Burden of serious harms from diagnostic error in the USA.
BMJ Qual Saf 2024 Jan 19; 33(2):109-20. doi: 10.1136/bmjqs-2021-014130..
Keywords: Healthcare Cost and Utilization Project (HCUP), Diagnostic Safety and Quality, Medical Errors, Patient Safety, Quality of Care, Adverse Events
Liberman AL, Wang Z, Zhu Y
Optimizing measurement of misdiagnosis-related harms using Symptom-Disease Pair Analysis of Diagnostic Error (SPADE): comparison groups to maximize SPADE validity.
The purpose of this paper was to clarify features of the Symptom-Disease Pair Analysis of Diagnostic Error (SPADE) approach to accurately measure diagnostic errors to assure that researchers utilize this method to yield valid results, as well as improve the validity of SPADE and related approaches to quantify diagnostic error in medicine. The researchers describe four types of comparators (intra-group and inter-group), detailing the reason for selecting one over the other and conclusions that can be drawn from these comparative analyses.
AHRQ-funded; HS027614.
Citation: Liberman AL, Wang Z, Zhu Y .
Optimizing measurement of misdiagnosis-related harms using Symptom-Disease Pair Analysis of Diagnostic Error (SPADE): comparison groups to maximize SPADE validity.
Diagnosis 2023 Aug 1; 10(3):225-34. doi: 10.1515/dx-2022-0130..
Keywords: Diagnostic Safety and Quality, Medical Errors, Adverse Events, Electronic Health Records (EHRs), Health Information Technology (HIT), Patient Safety
Giardina TD, Hunte H, Hill MA
Defining diagnostic error: a scoping review to assess the impact of the National Academies' report improving diagnosis in Health Care.
This study looked at peer-reviewed published literature to explore how researchers operationalize the National Academies of Science, Engineering, and Medicine’s (NASEM) definition of diagnostic error that was defined in their 2015 publication “Improving Diagnosis in Health Care”. Published literature was identified from October 2015 to February 2021. The authors also conducted subject matter expert interviews. Of the 34 studies identified, 16 were analyzed and abstracted to determine how diagnostic error was operationalized and measured. Studies were grouped by four themes: epidemiology, patient focus, measurement/surveillance, and clinician focus. Nine studies identified used the NASM definition. Five of those studies also operationalized with existing definitions proposed before the NASEM report, four operationalized the components of the NASEM definition, and three studies operationalized error using existing definitions only. Subject matter experts concluded that the NASEM definition functions as a foundation for researchers to conceptualize diagnostic error.
AHRQ-funded; 233201500022I; HS027280; HS025474; HS027363.
Citation: Giardina TD, Hunte H, Hill MA .
Defining diagnostic error: a scoping review to assess the impact of the National Academies' report improving diagnosis in Health Care.
J Patient Saf 2022 Dec 1;18(8):770-78. doi: 10.1097/pts.0000000000000999..
Keywords: Diagnostic Safety and Quality, Quality of Care, Medical Errors, Adverse Events, Healthcare Delivery
Shafer GJ, Singh H, Thomas EJ
Frequency of diagnostic errors in the neonatal intensive care unit: a retrospective cohort study.
The objective of this study was to determine the frequency and etiology of diagnostic errors during the first 7 days of admission for inborn neonatal intensive care unit (NICU) patients. The "Safer Dx NICU Instrument" was used to review electronic health records. The reviewers discovered that the frequency of diagnostic error in inborn NICU patients during the first 7 days of admission was 6.2%.
AHRQ-funded; HS027363.
Citation: Shafer GJ, Singh H, Thomas EJ .
Frequency of diagnostic errors in the neonatal intensive care unit: a retrospective cohort study.
J Perinatol 2022 Oct;42(10):1312-18. doi: 10.1038/s41372-022-01359-9..
Keywords: Newborns/Infants, Intensive Care Unit (ICU), Critical Care, Diagnostic Safety and Quality, Medical Errors, Adverse Events, Patient Safety, Electronic Health Records (EHRs), Health Information Technology (HIT)
Mahajan P, Mollen C, Alpern ER
An operational framework to study diagnostic errors in emergency departments: findings from a consensus panel.
The purpose of this study was to create an operational definition and framework to study diagnostic error in the emergency department setting. A multidisciplinary panel defined diagnostic errors, modified the National Academies of Sciences, Engineering, and Medicine's diagnostic process framework, and underscored the importance of outcome feedback to emergency department providers to promote learning and improvement related to diagnosis.
AHRQ-funded; HS024953.
Citation: Mahajan P, Mollen C, Alpern ER .
An operational framework to study diagnostic errors in emergency departments: findings from a consensus panel.
J Patient Saf 2021 Dec 1;17(8):570-75. doi: 10.1097/pts.0000000000000624..
Keywords: Diagnostic Safety and Quality, Emergency Department, Medical Errors, Adverse Events
Giardina TD, Korukonda S, Shahid U
Use of patient complaints to identify diagnosis-related safety concerns: a mixed-method evaluation.
This retrospective cohort study evaluated the use of patient complaint data to identify patient safety concerns related to diagnosis as an initial step to using this information to facilitate learning and improvement. Patient complaints submitted to the Geisinger healthcare system were reviewed with 2 cohorts from August to December 2017 (cohort 1) and January to June 2018 (cohort 2). The authors selected complaints more likely to be associated with diagnostic concerns in Geisinger’s existing complaint taxonomy. In cohort 1, 1865 complaint summaries were reviewed and 177 (9.5%) were identified as concerning. The review identified 39 diagnostic errors. In cohort 2, 2423 patient complaints were reviewed and 310 (12.8%) concerning reports were identified. A 10% sample contained give diagnostic errors. Most errors were categorized as “Clinical Care” issues.
AHRQ-funded; HS025474; HS027363.
Citation: Giardina TD, Korukonda S, Shahid U .
Use of patient complaints to identify diagnosis-related safety concerns: a mixed-method evaluation.
BMJ Qual Saf 2021 Dec;30(12):996-1001. doi: 10.1136/bmjqs-2020-011593..
Keywords: Diagnostic Safety and Quality, Patient Safety, Medical Errors, Adverse Events
Vaghani V, Wei L, U
Validation of an electronic trigger to measure missed diagnosis of stroke in emergency departments.
Diagnostic errors are major contributors to preventable patient harm. In this study, the investigators validated the use of an electronic health record (EHR)-based trigger (e-trigger) to measure missed opportunities in stroke diagnosis in emergency departments (EDs). The investigators concluded that a symptom-disease pair-based e-trigger identified missed diagnoses of stroke with a modest positive predictive value, underscoring the need for chart review validation procedures to identify diagnostic errors in large data sets.
AHRQ-funded; HS017820; HS024459.
Citation: Vaghani V, Wei L, U .
Validation of an electronic trigger to measure missed diagnosis of stroke in emergency departments.
J Am Med Inform Assoc 2021 Sep 18;28(10):2202-11. doi: 10.1093/jamia/ocab121..
Keywords: Stroke, Cardiovascular Conditions, Emergency Department, Diagnostic Safety and Quality, Medical Errors, Adverse Events
Mahajan P, Pai CW, Cosby KS
Identifying trigger concepts to screen emergency department visits for diagnostic errors.
The 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. In this study, the investigators 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.
AHRQ-funded; HS024953; HS027363.
Citation: Mahajan P, Pai CW, Cosby KS .
Identifying trigger concepts to screen emergency department visits for diagnostic errors.
Diagnosis 2021 Aug 26;8(3):340-46. doi: 10.1515/dx-2020-0122..
Keywords: Emergency Department, Diagnostic Safety and Quality, Medical Errors, Adverse Events, Patient Safety
Griffin JA, Carr K, Bersani K
Analyzing diagnostic errors in the acute setting: a process-driven approach.
In this study the authors describe an approach for analyzing failures in diagnostic processes in a small, enriched cohort of general medicine patients who expired during hospitalization and experienced medical error. Their objective was to delineate a systematic strategy for identifying frequent and significant failures in the diagnostic process to inform strategies for preventing adverse events due to diagnostic error.
AHRQ-funded; HS026613.
Citation: Griffin JA, Carr K, Bersani K .
Analyzing diagnostic errors in the acute setting: a process-driven approach.
Diagnosis 2021 Aug 23;23(9):77-88. doi: 10.1515/dx-2021-0033..
Keywords: Diagnostic Safety and Quality, Medical Errors, Adverse Events
Cifra CL, Custer JW, Singh H
Diagnostic errors in pediatric critical care: a systematic review.
This study is a systematic review on the prevalence, impact, and contributing factors related to diagnostic errors in the PICU. A database search was done for literature up through December 2019. Using specific criteria, 396 abstracts were screened, and 17 studies were included. Fifteen of 17 studies had an observational research design. Autopsy studies showed a 10-23% rate of missed major diagnosis with 5-16% of the errors having a potential adverse impact on survival and would have changed care management. Retrospective record review studies reported varying rates of diagnostic error from 8% in a general PICU population to 12% among unexpected critical admissions. About a quarter of those patients were discussed at PICU morbidity and mortality conferences. Most misdiagnosed conditions were cardiovascular, infectious, congenital, or neurologic. System, cognitive, and both system and cognitive factors were associated with diagnostic error but there is limited information on the impact of misdiagnosis.
AHRQ-funded; HS026965.
Citation: Cifra CL, Custer JW, Singh H .
Diagnostic errors in pediatric critical care: a systematic review.
Pediatr Crit Care Med 2021 Aug;22(8):701-12. doi: 10.1097/pcc.0000000000002735..
Keywords: Children/Adolescents, Diagnostic Safety and Quality, Medical Errors, Adverse Events, Patient Safety, Intensive Care Unit (ICU), Critical Care
Michelson KA, Williams DN, Dart AH
Development of a rubric for assessing delayed diagnosis of appendicitis, diabetic ketoacidosis and sepsis.
This study’s objective was to create a guide for objectively grading the likelihood of delayed diagnosis of appendicitis, new-onset diabetic ketoacidosis (DKA), and sepsis. Case vignettes were constructed for each condition and then presented to expert Delphi panels for review. In each vignette, the patient had a previous emergency department visit within 7 days of the delayed diagnosis. The panels graded the likelihood of a delayed diagnosis on a five-point scale. Consensus was achieved within three Delphi rounds for all appendicitis and sepsis vignettes, and 77% of DKA vignettes. The authors created a case review guide from the consensus scores that will aid researchers and quality improvement specialists in objective case review to determine if delayed diagnosis had occurred for those three conditions.
AHRQ-funded; HS026503.
Citation: Michelson KA, Williams DN, Dart AH .
Development of a rubric for assessing delayed diagnosis of appendicitis, diabetic ketoacidosis and sepsis.
Diagnosis 2021;8(2):219-25. doi: 10.1515/dx-2020-0035..
Keywords: Diagnostic Safety and Quality, Sepsis, Medical Errors, Adverse Events, Patient Safety
Marshall TL, Ipsaro AJ, Le M
Increasing physician reporting of diagnostic learning opportunities.
This study investigated methods to improve physician reporting of diagnostic errors at the pediatric division of a hospital. In that pediatric hospital medicine (PHM) division only 1 diagnostic-related safety event was reported in the preceding 4 years. The authors aimed to improve attending physician reporting of suspected diagnostic errors from 0 to 2 per 100 PHM patient admissions within 6 months. The improvement team used the Model for Improvement and used the term diagnostic learning opportunity (DLO) with clinicians as opposed to diagnostic error to lessen the stigma. They developed an electronic reporting form and encouraged its use through reminders, scheduled reflection time, and monthly progress reports. Over the course of 13 weeks, there was an increase from 0 to 1.6 per patient admission reports files. Most events (66%) were true diagnostic errors.
AHRQ-funded; HS023827.
Citation: Marshall TL, Ipsaro AJ, Le M .
Increasing physician reporting of diagnostic learning opportunities.
Pediatrics 2021 Jan;147(1). doi: 10.1542/peds.2019-2400..
Keywords: Children/Adolescents, Diagnostic Safety and Quality, Medical Errors, Adverse Events, Patient Safety, Hospitals, Quality Improvement, Quality of Care
Salmasian H, Blanchfield BB, Joyce K
Association of display of patient photographs in the electronic health record with wrong-patient order entry errors.
Wrong-patient order entry (WPOE) errors have a high potential for harm; these errors are particularly frequent wherever workflows are complex and multitasking and interruptions are common, such as in the emergency department (ED). The purpose of this study was to evaluate whether the use of noninterruptive display of patient photographs in the banner of the electronic health record (EHR) is associated with a decreased rate of WPOE errors.
AHRQ-funded; HS024713.
Citation: Salmasian H, Blanchfield BB, Joyce K .
Association of display of patient photographs in the electronic health record with wrong-patient order entry errors.
AMA Netw Open 2020 Nov 2;3(11):e2019652. doi: 10.1001/jamanetworkopen.2020.19652..
Keywords: Electronic Health Records (EHRs), Health Information Technology (HIT), Medical Errors, Adverse Drug Events (ADE), Adverse Events, Medication, Medication: Safety, Patient Safety, Diagnostic Safety and Quality
Dadlez NM, Adelman J, Bundy DG
Contributing factors for pediatric ambulatory diagnostic process errors: Project RedDE.
This study examined root causes of three common pediatric diagnostic errors by having 31 practices enrolled in a national QI collaborative perform monthly “mini-RCAs” (mini root cause analyses). The diagnoses errors studied were missed adolescent depression, missed elevated blood pressure, and missed actionable laboratory values. Twenty-eight practices submitted 184 mini-RCAs with the most common causes being patient volume (adolescent depression and elevated BP), inadequate staffing (adolescent depression), clinic milieu (elevated BP), written communication and provider knowledge (actionable laboratory values), and electronic health records (EHRs) – (elevated BP and actionable laboratory values). The median number of mini-RCAs submitted was 6.
AHRQ-funded; HS024538; HS024713; HS026121.
Citation: Dadlez NM, Adelman J, Bundy DG .
Contributing factors for pediatric ambulatory diagnostic process errors: Project RedDE.
Pediatr Qual Saf 2020 May-Jun;5(3):e299. doi: 10.1097/pq9.0000000000000299..
Keywords: Children/Adolescents, Diagnostic Safety and Quality, Quality Improvement, Quality of Care, Medical Errors, Adverse Events, Patient Safety
Cifra CL, Ten Eyck P, Dawson JD
Factors associated with diagnostic error on admission to a PICU: a pilot study.
This pilot retrospective cohort study examined errors in pediatric ICUs (PICUs) for children during the first 12 hours after PICU admission. A structured tool (Safer Dx) was used to identify diagnostic error in an academic tertiary institution. Out of 50 patients, 4 (8%) had diagnostic errors. The errors were in diagnoses of chronic ear infection, intracranial pressure (two cases), and Bartonella encephalitis. This pilot study will be expanded into a larger and more definitive multicenter study.
AHRQ-funded; HS022087.
Citation: Cifra CL, Ten Eyck P, Dawson JD .
Factors associated with diagnostic error on admission to a PICU: a pilot study.
Pediatr Crit Care Med 2020 May;21(5):e311-e15. doi: 10.1097/pcc.0000000000002257..
Keywords: Children/Adolescents, Diagnostic Safety and Quality, Medical Errors, Adverse Events, Patient Safety, Critical Care, Intensive Care Unit (ICU), Hospitals
Soleimani J, Pinevich Y, Barwise AK
Feasibility and reliability testing of manual electronic health record reviews as a tool for timely identification of diagnostic error in patients at risk.
Although diagnostic error (DE) is a significant problem, it remains challenging for clinicians to identify it reliably and to recognize its contribution to the clinical trajectory of their patients. The purpose of this work was to evaluate the reliability of real-time electronic health record (EHR) reviews using a search strategy for the identification of DE as a contributor to the rapid response team (RRT) activation. Early and accurate recognition of critical illness is of paramount importance.
AHRQ-funded; HS026609.
Citation: Soleimani J, Pinevich Y, Barwise AK .
Feasibility and reliability testing of manual electronic health record reviews as a tool for timely identification of diagnostic error in patients at risk.
Appl Clin Inform 2020 May;11(3):474-82. doi: 10.1055/s-0040-1713750..
Keywords: Electronic Health Records (EHRs), Health Information Technology (HIT), Diagnostic Safety and Quality, Medical Errors, Adverse Events, Patient Safety
Sheehan SE, Safdar N, Singh H
Detection and remediation of misidentification errors in radiology examination ordering.
In this study, the investigators described the pilot testing of a quality improvement methodology using electronic trigger tools and preimaging checklists to detect "wrong-side" misidentification errors in radiology examination ordering, and to measure staff adherence to departmental policy in error remediation. The investigators concluded that their trigger tool enabled the detection of substantially more imaging ordering misidentification errors than preimaging safety checklists alone, with a high positive predictive value.
AHRQ-funded; HS022087; HS017820.
Citation: Sheehan SE, Safdar N, Singh H .
Detection and remediation of misidentification errors in radiology examination ordering.
Appl Clin Inform 2020 Jan;11(1):79-87. doi: 10.1055/s-0039-3402730..
Keywords: Medical Errors, Adverse Events, Diagnostic Safety and Quality, Patient Safety, Imaging, Quality Improvement, Quality of Care
Shafer G, Singh H, Suresh G
Diagnostic errors in the neonatal intensive care unit: state of the science and new directions.
In this narrative review, the authors discuss how the concept of diagnostic errors framed as missed opportunities can be applied to the non-linear nature of diagnosis in a critical care environment such as the NICU. They then explore how the etiology of an error in diagnosis can be related to both individual cognitive factors as well as organizational and systemic factors - all of which often contribute to the error.
AHRQ-funded; HS022087.
Citation: Shafer G, Singh H, Suresh G .
Diagnostic errors in the neonatal intensive care unit: state of the science and new directions.
Semin Perinatol 2019 Dec;43(8):151175. doi: 10.1053/j.semperi.2019.08.004..
Keywords: Newborns/Infants, Diagnostic Safety and Quality, Neonatal Intensive Care Unit (NICU), Medical Errors, Adverse Events, Patient Safety
Singh H, Graber ML, Hofer TP
Measures to improve diagnostic safety in clinical practice.
In this paper, the investigators discuss how the need to develop measures to improve diagnostic performance could move forward at a time when the scientific foundation needed to inform measurement is still evolving. They highlight challenges and opportunities for developing potential measures of "diagnostic safety" related to clinical diagnostic errors and associated preventable diagnostic harm. In doing so, they propose a starter set of measurement concepts for initial consideration that seem reasonably related to diagnostic safety and call for these to be studied and further refined.
AHRQ-funded; HS022087.
Citation: Singh H, Graber ML, Hofer TP .
Measures to improve diagnostic safety in clinical practice.
J Patient Saf 2019 Dec;15(4):311-16. doi: 10.1097/pts.0000000000000338.
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Keywords: Patient Safety, Diagnostic Safety and Quality, Healthcare Delivery, Quality Improvement, Quality of Care, Medical Errors, Adverse Events
Bundy DG, Singh H, Stein RE
The design and conduct of Project RedDE: a cluster-randomized trial to reduce diagnostic errors in pediatric primary care.
This paper discusses the results of Project RedDE, which was a virtual collaborative quality improvement study to reduce diagnostic errors in pediatric primary care practices. Forty-three practices were initially recruited, with a total of 31 practices left at the end due to practice dropout and two participating practices merging. This study was a randomized controlled trial targeting three common diagnostic errors (missed diagnoses of adolescent depression, abnormal blood pressure, and lack of followup for abnormal laboratory results). Contamination across study groups was a recurring problem, but risk mitigations were used. Electronic health records contributed to teams’ success.
AHRQ-funded; HS203608.
Citation: Bundy DG, Singh H, Stein RE .
The design and conduct of Project RedDE: a cluster-randomized trial to reduce diagnostic errors in pediatric primary care.
Clin Trials 2019 Apr;16(2):154-64. doi: 10.1177/1740774518820522..
Keywords: Adverse Events, Children/Adolescents, Diagnostic Safety and Quality, Medical Errors, Prevention, Primary Care, Quality of Care, Quality Improvement
Lacson R, Cochon L, Ip I
Classifying safety events related to diagnostic imaging from a safety reporting system using a human factors framework.
This study measured the prevalence of safety events related to diagnostic imaging reported to an electronic safety reporting system. The authors evaluated reports all system reports from 2015 at an academic medical center. Out of 11,570 safety reports submitted, only 7% were related to diagnostic imaging. The adverse event was reported as either result communication or harm during the imaging procedure itself. The harms were rates from 0 to 4 by the reporter. Harms from 2-4 were considered as “potential harm."
AHRQ-funded; HS024722.
Citation: Lacson R, Cochon L, Ip I .
Classifying safety events related to diagnostic imaging from a safety reporting system using a human factors framework.
J Am Coll Radiol 2019 Mar;16(3):282-88. doi: 10.1016/j.jacr.2018.10.015..
Keywords: Adverse Events, Diagnostic Safety and Quality, Imaging, Patient Safety, Medical Errors
Bates DW, Singh H
Two decades since To Err Is Human: an assessment of progress and emerging priorities in patient safety.
This paper comments on the progress made in improving patient safety since the 1999 report from The Institute of Medicine titled “To Err is Human” was published. This landmark report highlighted problem areas, and since then there has been a number of effective interventions to prevent hospital-acquired infections and improve medication safety. Additional areas for improvement have also been identified in the past two decades, including outpatient care, diagnostic, errors and the use of health information technology. The authors believe that electronic data developments can help increase patient safety even further.
AHRQ-funded; HS022087; HS017820.
Citation: Bates DW, Singh H .
Two decades since To Err Is Human: an assessment of progress and emerging priorities in patient safety.
Health Aff 2018 Nov;37(11):1736-43. doi: 10.1377/hlthaff.2018.0738..
Keywords: Adverse Drug Events (ADE), Adverse Events, Diagnostic Safety and Quality, Electronic Health Records (EHRs), Health Information Technology (HIT), Medical Errors, Medication, Medication: Safety, Patient Safety, Prevention
Bergl PA, Nanchal RS, Singh H
Diagnostic error in the critically ill: defining the problem and exploring next steps to advance intensive care unit safety.
Despite progress in ICU safety, diagnostic errors remain largely unexplored and under-studied in critical care. Compared to other safety problems, diagnostic errors are more difficult to identify and, due to the intricacies of the diagnostic process, are more difficult to unravel. This paper discusses diagnostic error in critically ill patients, defines the problem and explores next steps to advance ICU safety.
AHRQ-funded; HS022087.
Citation: Bergl PA, Nanchal RS, Singh H .
Diagnostic error in the critically ill: defining the problem and exploring next steps to advance intensive care unit safety.
Ann Am Thorac Soc 2018 Aug;15(8):903-07. doi: 10.1513/AnnalsATS.201801-068PS..
Keywords: Adverse Events, Critical Care, Diagnostic Safety and Quality, Intensive Care Unit (ICU), Medical Errors, Patient Safety