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- Adverse Drug Events (ADE) (2)
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- Critical Care (6)
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- (-) Diagnostic Safety and Quality (38)
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- Neonatal Intensive Care Unit (NICU) (1)
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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 38 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
Cifra CL, Custer JW, Smith CM
Prevalence and characteristics of diagnostic error in pediatric critical care: a multicenter study.
This study’s objective was to determine the prevalence and characteristics of diagnostic errors and identify factors associated with error in patients admitted to the PICU. This multicenter cohort study used structured medical record review by trained clinicians using the Revised Safer Dx instrument to identify diagnostic error (defined as missed opportunities in diagnosis). The cohort included 882 randomly selected patients 0-18 years old who were nonelectively admitted to participating PICUs. Of these admissions, 13 (1.5%) had a diagnostic error up to 7 days after PICU admission, with infections (46%) and respiratory conditions (23%) being the most missed diagnoses. One diagnostic error caused a prolonged hospital stay. Common missed diagnostic opportunities included failure to consider the diagnosis despite a suggestive history and failure to broaden diagnostic testing, both at 69%. Unadjusted analysis identified more diagnostic errors in patients with atypical presentations (23.1% vs 3.6%), neurologic chief complaints (46.2% vs 18.8%), admitting intensivists greater than or equal to 45 years old (92.3% vs 65.1%), admitting intensivists with more service weeks/year (mean 12.8 vs 10.9 weeks), and diagnostic uncertainty on admission (77% vs 25.1%). Generalized linear mixed models determined that atypical presentation (odds ratio [OR] 4.58) and diagnostic uncertainty on admission (OR 9.67) were significantly associated with diagnostic error.
AHRQ-funded; HS026965.
Citation: Cifra CL, Custer JW, Smith CM .
Prevalence and characteristics of diagnostic error in pediatric critical care: a multicenter study.
Crit Care Med 2023 Nov; 51(11):1492-501. doi: 10.1097/ccm.0000000000005942..
Keywords: Children/Adolescents, Diagnostic Safety and Quality, Critical Care, Intensive Care Unit (ICU), Medical Errors, Patient Safety
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
Luximon DC, Ritter T, Fields E
Development and interinstitutional validation of an automatic vertebral-body misalignment error detector for cone-beam CT-guided radiotherapy.
The purpose of this study was to develop an automatic error detection algorithm that uses a three-branch convolutional neural network error detection model (EDM) to detect off-by-one vertebral-body misalignments using planning computed tomography (CT) images and setup CBCT images. The researchers collected algorithm training and test data from 480 patients undergoing radiotherapy treatment at two radiotherapy clinics. One model (EDM(1) ) was trained solely on data from institution 1. EDM(1) was further trained on a dataset from institution 2 to produce a fine-tuned model, EDM(2) . Another model, EDM(3), was trained using a training dataset composed of data from both institutions. The study found that when applied to the combined test set, EDM(1) , EDM(2) , and EDM(3) resulted in an area under curve of 99.5%, 99.4%, and 99.5%, respectively. EDM(1) achieved a sensitivity of 96% and 88% on Institution 1 and Institution 2 test set, respectively. EDM(2) obtained a sensitivity of 95% on each institution's test set. EDM(3) achieved a sensitivity of 95% and 88% on Institution 1 and Institution 2 test set, respectively. The researchers concluded that in CBCT-guided radiotherapy, the proposed algorithm demonstrated accuracy in identifying off-by-one vertebral-body misalignments that was sufficiently high enough to justify implementation in practice.
AHRQ-funded; HS026486.
Citation: Luximon DC, Ritter T, Fields E .
Development and interinstitutional validation of an automatic vertebral-body misalignment error detector for cone-beam CT-guided radiotherapy.
Med Phys 2022 Oct;49(10):6410-23. doi: 10.1002/mp.15927..
Keywords: Imaging, Diagnostic Safety and Quality, Medical Errors, Patient Safety
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)
Marshall TL, Rinke ML, Olson APJ
Diagnostic error in pediatrics: a narrative review.
This narrative review focuses on the relative paucity of large, high-quality studies of diagnostic errors and what is known at present about the incident and epidemiology as well as the established research for identifying, evaluating, and reducing diagnostic errors. The authors propose several key research questions aimed at addressing persistent gaps in the pediatric diagnostic error literature. The authors state that additional research is needed to better establish the epidemiology of diagnostic errors in pediatrics, including identifying high-risk clinical scenarios, patient populations, and groups of diagnoses.
AHRQ-funded; HS023827; HS026644.
Citation: Marshall TL, Rinke ML, Olson APJ .
Diagnostic error in pediatrics: a narrative review.
Pediatrics 2022 Mar;149(Suppl 3). doi: 10.1542/peds.2020-045948D..
Keywords: Children/Adolescents, Diagnostic Safety and Quality, Patient Safety, Medical Errors
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
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
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
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
Medford-Davis LN, Singh H, Mahajan P
Diagnostic decision-making in the emergency department.
Emergency providers must often diagnose from undifferentiated symptoms, without previous knowledge of the patient. Failure to provide an accurate assessment of the problem or to communicate the problem to the patient is diagnostic error. This article considers methods to monitor diagnostic error in emergency departments.
AHRQ-funded; HS024953.
Citation: Medford-Davis LN, Singh H, Mahajan P .
Diagnostic decision-making in the emergency department.
Pediatr Clin North Am 2018 Dec;65(6):1097-105. doi: 10.1016/j.pcl.2018.07.003..
Keywords: Emergency Department, Diagnostic Safety and Quality, Decision Making, Medical Errors, Patient Safety
Cochon L, Lacson R, Wang A
Assessing information sources to elucidate diagnostic process errors in radiologic imaging - a human factors framework.
The purpose of this study was to assess information sources that may elucidate errors related to radiologic diagnostic imaging, quantify the incidence of potential safety events from each source, and quantify the number of steps involved from diagnostic imaging chain and socio-technical factors. Information sources can elucidate errors in various steps within the diagnostic imaging workflow and can provide insight into socio-technical factors that impact patient safety in the diagnostic process.
AHRQ-funded; HS024722.
Citation: Cochon L, Lacson R, Wang A .
Assessing information sources to elucidate diagnostic process errors in radiologic imaging - a human factors framework.
J Am Med Inform Assoc 2018 Nov;25(11):1507-15. doi: 10.1093/jamia/ocy103..
Keywords: Diagnostic Safety and Quality, Imaging, Medical Errors, Patient Safety
Berenson R, Singh H
Payment innovations to improve diagnostic accuracy and reduce diagnostic error.
Researchers examined ways that payment innovations could be used to improve diagnostic accuracy and reduce diagnostic error among Medicare patients. They recommended three different approaches: 1) coding changes in the Medicare Physician Fee schedule; new Alternative Payment Models (APMs) that could improve accuracy in challenging cases and even provide second or third opinions; and 3) have a method that accurate diagnoses would trigger APM payments and establish payment amounts.
AHRQ-funded; HS022087; HS017820.
Citation: Berenson R, Singh H .
Payment innovations to improve diagnostic accuracy and reduce diagnostic error.
Health Aff 2018 Nov;37(11):1828-35. doi: 10.1377/hlthaff.2018.0714..
Keywords: Diagnostic Safety and Quality, Payment, Medical Errors, Medicare, Patient Safety, Quality of Care
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