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Research Studies is a monthly compilation of research articles funded by AHRQ or authored by AHRQ researchers and recently published in journals or newsletters.
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1 to 20 of 20 Research Studies DisplayedGiardina 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
Lasser EC, Heughan JA, Lai AY
Patient perceptions of safety in primary care: a qualitative study to inform care.
The authors sought to understand the patient perspective on patient safety in patient-centered medical homes (PCMHs). Using focus groups/interviews, they found overarching themes focused on (1) clear and timely communication with and between clinicians and (2) trust in the care team, including being heard, respected, and treated as a whole person. Other themes included sharing of and access to information, patient education and patient-centered medication reconciliation process, clear documentation for the diagnostic process, patient-centered comprehensive visits, and timeliness of care.
AHRQ-funded; HS024859.
Citation: Lasser EC, Heughan JA, Lai AY .
Patient perceptions of safety in primary care: a qualitative study to inform care.
Curr Med Res Opin 2021 Nov;37(11):1991-99. doi: 10.1080/03007995.2021.1976736..
Keywords: Patient Safety, Patient Experience, Primary Care, Patient-Centered Healthcare
Nehls N, Yap TS, Salant T
Systems engineering analysis of diagnostic referral closed-loop processes.
This systems engineering (SE) analysis of diagnostic referral closed-loop processes examines process logic, variation, reliability, and failures for completing diagnostic referrals originating in two primary care practices serving different demographics, using dermatology as an illustrating use case. Research has shown that there is a 65-73% failure rate in completing diagnostic referrals, which is a significant patient safety problem. An interdisciplinary team collaborated to understand processes of initiating and completing diagnostic referrals. Cross-functional process maps were developed through iterative group interviews with an urban community-based health center and a teaching practice within a large academic medical center. Results were used to conduct an engineering process analysis, assess variation between and within practices, and identify common failure modes and potential solutions.
AHRQ-funded; HS027282.
Citation: Nehls N, Yap TS, Salant T .
Systems engineering analysis of diagnostic referral closed-loop processes.
BMJ Open Qual 2021 Nov;10(4). doi: 10.1136/bmjoq-2021-001603..
Keywords: Diagnostic Safety and Quality, Primary Care, Patient Safety
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
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
Cifra CL, Sittig DF, Singh H
Bridging the feedback gap: a sociotechnical approach to informing clinicians of patients' subsequent clinical course and outcomes.
This paper discusses challenges to the development of systems for effective patient outcome feedback to improve diagnosis and proposes the application of a sociotechnical approach using health information technology (HIT) to support the implementation of such systems. It discusses current barriers to effective clinician feedback, reasons for them, and features of potential IT solutions. Evaluation and implementation of the feedback process within a sociotechnical health system are then discussed. The authors use an eight-dimension sociotechnical model for studying health IT by authors Sittig and Singh. The eight dimensions are hardware and software; clinical content; human–computer interface; people; workflow and communication; organisational policies and procedures; external rules, regulations and pressures; and system measurement and monitoring. A table is included that shows the potential considerations for each dimension.
AHRQ-funded; 33201500022I; HS027363.
Citation: Cifra CL, Sittig DF, Singh H .
Bridging the feedback gap: a sociotechnical approach to informing clinicians of patients' subsequent clinical course and outcomes.
BMJ Qual Saf 2021 Jul;30(7):591-97. doi: 10.1136/bmjqs-2020-012464..
Keywords: Health Information Technology (HIT), Diagnostic Safety and Quality, Patient Safety, Quality Improvement, Quality of Care
Enayati M, Sir M, Zhang X
Monitoring diagnostic safety risks in emergency departments: protocol for a machine learning study.
This study’s objective will be to identify variables associated with diagnostic errors in emergency departments using large-scale EHR data and machine learning techniques. It will use trigger algorithms with electronic health record (EHR) data repositories to generate a large data set of records that are labeled trigger-positive or trigger-negative, depending on if they meet certain criteria. This study will be conducted by 2 academic medical centers with affiliated community hospitals.
AHRQ-funded; HS027363; HS026622.
Citation: Enayati M, Sir M, Zhang X .
Monitoring diagnostic safety risks in emergency departments: protocol for a machine learning study.
JMIR Res Protoc 2021 Jun 14;10(6):e24642. doi: 10.2196/24642..
Keywords: Emergency Department, Diagnostic Safety and Quality, Patient Safety, Risk, Electronic Health Records (EHRs), Health Information Technology (HIT)
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
Lacson R, Cochon L, Ching PR
Integrity of clinical information in radiology reports documenting pulmonary nodules.
Researchers sought to quantify the integrity, measured as completeness and concordance with a thoracic radiologist, of documenting pulmonary nodule characteristics in CT reports, and to assess impact on making follow-up recommendations. Their retrospective cohort study was performed at an academic medical center and natural language processing was used on radiology reports of CT scans of chest, abdomen, or spine to assess presence of pulmonary nodules. They found that essential pulmonary nodule characteristics were under-reported, potentially impacting recommendations for pulmonary nodule follow-up. They concluded that the lack of documentation of pulmonary nodule characteristics in radiology reports was common, with the potential for compromising patient care and clinical decision support tools.
AHRQ-funded; HS024722.
Citation: Lacson R, Cochon L, Ching PR .
Integrity of clinical information in radiology reports documenting pulmonary nodules.
J Am Med Inform Assoc 2021 Jan 15;28(1):80-85. doi: 10.1093/jamia/ocaa209..
Keywords: Imaging, Diagnostic Safety and Quality, Electronic Health Records (EHRs), Health Information Technology (HIT), 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
Yang J, Wang L, Phadke
Development and validation of a deep learning model for detection of allergic reactions using safety event reports across hospitals,
Although critical to patient safety, health care-related allergic reactions are challenging to identify and monitor. The purpose of this study was to develop a deep learning model to identify allergic reactions in the free-text narrative of hospital safety reports and evaluate its generalizability, efficiency, productivity, and interpretability. The investigators concluded that their study showed that a deep learning model could accurately and efficiently identify allergic reactions using free-text narratives written by a variety of health care professionals.
AHRQ-funded; HS025375.
Citation: Yang J, Wang L, Phadke .
Development and validation of a deep learning model for detection of allergic reactions using safety event reports across hospitals,
JAMA Netw Open 2020 Nov 2;3(11):e2022836. doi: 10.1001/jamanetworkopen.2020.22836..
Keywords: Diagnostic Safety and Quality, Health Information Technology (HIT), Patient Safety
Lacson R, Healey MJ, Cochon LR
Unscheduled radiologic examination orders in the electronic health record: a novel resource for targeting ambulatory diagnostic errors in radiology.
The purpose of this study was to assess the prevalence of unscheduled radiologic examination orders in an electronic health record and to assess the proportion of unscheduled orders that are clinically necessary. Unscheduled radiologic examination orders were retrieved for seven modalities: computed tomography, magnetic resonance imaging, ultrasound, obstetric ultrasound, bone densitometry, mammography, and fluoroscopy. Findings showed that large numbers of radiologic examination orders remain unscheduled in the electronic health record. Identifying and performing clinically necessary unscheduled radiologic examination orders may help reduce diagnostic errors related to diagnosis and treatment delays and enhance patient safety.
AHRQ-funded; HS024722.
Citation: Lacson R, Healey MJ, Cochon LR .
Unscheduled radiologic examination orders in the electronic health record: a novel resource for targeting ambulatory diagnostic errors in radiology.
J Am Coll Radiol 2020 Jun;17(6):765-72. doi: 10.1016/j.jacr.2019.12.021..
Keywords: Electronic Health Records (EHRs), Health Information Technology (HIT), Diagnostic Safety and Quality, Imaging, Patient Safety
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
Krantz MS, Liu Y, Phillips EJ
Anaphylaxis to PEGylated liposomal echocardiogram contrast in a patient with IgE-mediated macrogol allergy.
The authors describe a case of anaphylaxis to PEG 5000-conjugated liposomal perflutren, a perfluorocarbon gas used as echocardiography contrast. They conclude that, given the severity of the patient’s reactions, allergists, cardiologists, and radiologists should become aware of the possibility of hypersensitivity reactions to macrogols to facilitate prompt diagnosis, treatment, and future avoidance. They suggested that use of PEGylated liposomal perflutren and other drugs and devices containing HMW PEG be avoided in favor of alternatives when patients report previous immediate hypersensitivity reactions consistent with severe macrogol allergy. They recommended further studies.
AHRQ-funded; HS026395.
Citation: Krantz MS, Liu Y, Phillips EJ .
Anaphylaxis to PEGylated liposomal echocardiogram contrast in a patient with IgE-mediated macrogol allergy.
J Allergy Clin Immunol Pract 2020 Apr;8(4):1416-19.e3. doi: 10.1016/j.jaip.2019.12.041..
Keywords: Adverse Events, Diagnostic Safety and Quality, Patient Safety, Case Study
LaHue SC, Albers K, Goldman S
Cervical dystonia incidence and diagnostic delay in a multiethnic population.
This study examined rates of diagnostic delay of cervical dystonia (CD) and the population of CD patients. Cases were identified from electronic medical records and multistage screening of more than 3 million Kaiser Permanente Northern California members from 2003-2007. CD incidence is greater in women and increases with age. About half of CD patients had a diagnostic delay. They were first given diagnoses of essential tremor, cervical disc disease, neck sprain/strain, anxiety and depression. Adverse effects are associated with diagnostic delay.
AHRQ-funded; HS018413.
Citation: LaHue SC, Albers K, Goldman S .
Cervical dystonia incidence and diagnostic delay in a multiethnic population.
Mov Disord 2020 Mar;35(3):450-56. doi: 10.1002/mds.27927..
Keywords: Neurological Disorders, Diagnostic Safety and Quality, Patient Safety, Quality of Care
Meyer AND, Giardina TD, Spitzmueller C
Patient perspectives on the usefulness of an artificial intelligence-assisted symptom checker: cross-sectional survey study.
This study examined patients’ experiences using an artificial intelligence (AI)-assisted online symptom checker and their doctors’ reactions to that use. From March 2 through March 15, 2018 an online survey was conducted of US users of the Isabel Symptom Checker within 6 months of their use. The majority of users were women, white, and had a mean age of 48. Overall, patients had a positive experience with the symptom checker and felt they would use it again (91.4%). About 48% discussed the findings with their physician and felt about 40% of their physicians were interested. Patients who had previously experienced diagnostic errors were more likely to use the symptom checker to determine if they should seek care.
AHRQ-funded; HS025474; HS027363.
Citation: Meyer AND, Giardina TD, Spitzmueller C .
Patient perspectives on the usefulness of an artificial intelligence-assisted symptom checker: cross-sectional survey study.
J Med Internet Res 2020 Jan 30;22(1):e14679. doi: 10.2196/14679..
Keywords: Clinical Decision Support (CDS), Health Information Technology (HIT), Diagnostic Safety and Quality, 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
