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Showing results for tags 'Diagnostic error'.
Found 148 results
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Content ArticleMost healthcare organisations (HCOs) find diagnostic errors hard to address. Singh et al. developed a checklist (the Safer Dx Checklist) of 10 high-priority safety practices HCOs can use to conduct a proactive risk assessment to address diagnostic error.
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News Article
Sepsis: Perforated bowel Barry mum told to drink tea
Patient-Safety-Learning posted a news article in News
A mum suffered a perforated bowel and sepsis after being told she was anxious and should take constipation medication and drink peppermint tea. Farrah Moseley-Brown was in "agonising pain" after having her second son, Clay, but the hospital sent her home. Because of the delay in treating her, Ms Moseley-Brown, 28, of Barry, Vale of Glamorgan, now has a stoma. Cardiff and Vale health board admitted failures in her care and gave its "sincere apologies". Since the error, Ms Moseley-Brown has turned to TikTok to inform people about the dangers of sepsis and has had 15 million views one one video alone. She was booked into University Hospital Wales, Cardiff, for a Caesarean on 7 May 2020. After Clay was born, Ms Moseley-Brown lost about two-and-a-half pints of blood and needed further surgery to stem the bleeding. "I felt really unwell and I said this to the nurses and the staff at the hospital which they didn't listen to. They kept saying it was after-pain but it was just agonising," Ms Moseley-Brown said. Read full story Source: BBC News, 25 August 2023 -
Content ArticleDiagnostic error research has largely focused on individual clinicians’ decision making and system design, largely overlooking information from patients. This article in the journal Health Affairs analysed a unique data source of patient- and family-reported error narratives to explore factors that contribute to diagnostic errors. The analysis identified 224 instances of behavioural and interpersonal factors that reflected unprofessional clinician behaviour, including ignoring patients’ knowledge, disrespecting patients, failing to communicate and manipulation or deception. The authors concluded that patients’ perspectives can lead to a more comprehensive understanding of why diagnostic errors occur and help develop strategies for mitigation. They argue that health systems should develop and implement formal programs to collect patients’ experiences with the diagnostic process and use these data to promote an organisational culture that strives to reduce harm from diagnostic error.
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Content ArticleCalibration, defined as alignment between a person’s diagnostic accuracy and their confidence in that accuracy, is an essential component of diagnostic excellence. Miscalibration—the misalignment between a person’s diagnostic accuracy and their confidence in that accuracy—can manifest as either overconfidence or underconfidence and can have serious consequences for patient diagnosis. This resource about calibration from the US Agency for Healthcare Research and Quality (AHRQ) is primarily aimed at individual clinicians whose scope of practice includes diagnosis. It focuses on processes involved in making a diagnosis and the outcome of giving an explanatory label to patients after these processes unfold.
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Content ArticleMost people experience a diagnostic error at least once in their lifetime. Patients’ experiences with their diagnosis could provide important insights when setting research priorities to reduce diagnostic error. The objective of this study from Zwaan et al. was to engage patients in research agenda setting for improving diagnosis. Patients were involved in generating, discussing, prioritising, and ranking of research questions for diagnostic error reduction.
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Content ArticleThis article looks at why health journalists should be more thorough in their approach to covering news relating to diagnostic errors. Leading researchers suggest that health care providers have done little to address the problem of diagnostic errors since a seminal report was released by the Institute of Medicine in 2015 describing the widespread harms from missed and delayed diagnoses. The article looks at the issues relating to diagnosis and highlights the importance of journalists reporting on solutions as well as stories of harm. It also focuses on how health journalism can play a key role in holding healthcare organisations to account.
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Content ArticleSafety netting is a consultation technique to communicate uncertainty, provide patient information on red-flag symptoms, and plan for future appointments to ensure timely re-assessment of a patient’s condition. It is a way of managing clinical risk and helping patients identify the need to seek further medical help if their condition fails to improve, changes, or if they have concerns about their health. Former GP Professor Paul Silverston discusses the purpose of safety-netting and offers advice on a structured approach to implementing it in practice. Further reading on safety netting: Safety-netting in general practice: how to manage uncertain diagnoses Optimising GPs’ communication of advice to facilitate patients’ self-care and prompt follow-up when the diagnosis is uncertain: a realist review of ‘safety-netting’ in primary care
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Event
WPA Patient Safety Workshop: Diagnostic Errors
Sam posted an event in Community Calendar
Diagnostic error is the failure to establish an accurate and timely explanation of the patient’s health problem(s) or failure to communicate that explanation to the patient. The global burden of diagnostic errors is significant and has far-reaching implications for patients, healthcare systems, and society as a whole. Patient engagement plays a vital role in mitigating diagnostic errors by leveraging the unique knowledge, perspectives, and experiences of patients. Collaborative decision-making and open communication can significantly enhance the accuracy and quality of diagnostic processes, leading to improved patient care. Join the World Patient Alliance workshop on diagnostic errors and learn from leading healthcare providers and patient advocates on what is the global burden of diagnostic errors and how these can be reduced. Register -
News Article
'Hidden' rise in blood clot deaths 'breaking families' warns charity
Patient Safety Learning posted a news article in News
Thrombosis UK has warned that deaths involving blood clots are higher than expected as it called for more transparency over the work hospitals are doing to reduce the risk for patients. Before the pandemic hit, hospitals were regularly publishing data on the number of patients who had been risk assessed for blood clots. In March 2020, the NHS in England took the decision to suspend the data collection on venous thromboembolism (also known as VTE) risk assessments to “release capacity in providers and commissioners to manage the Covid-19 pandemic”. But the data collection and publication is yet to resume. The charity said the data shows how many VTE cases are missed in hospitals. One bereaved man described how his mother died last year after the condition was missed. Tim Edwards, 42, said healthcare workers missed signs of the condition while Jennifer Edwards, 74, was in hospital on the south coast. Despite having many symptoms of a pulmonary embolism she was discharged home and died three days later. Mr Edwards said: ““My mother’s symptoms were missed from her admission to hospital right up to her time in the cardiology department. “She was discharged and passed away three days after phoning the NHS with shortness of breath. She should not have died. I took it upon myself to enquire about the circumstances surrounding her death and was overwhelmed by the lack of care taken. “Sadly, I know this is not an isolated case.” Read full story Source: Wales Online, 12 May 2023 Further reading on the hub: Pulmonary embolism misdiagnosis – a systemic problem (a blog from Tim Edwards) Independent review of pulmonary embolism fatalities in England & Wales – recent trends, excess deaths, their causes and risk management concerns (Tim Edwards) Jenny, and why we must learn from her misdiagnosis of pulmonary embolism National Voices: Pulmonary embolism misdiagnosis - a blog by Helen Hughes. -
Content ArticlePatient Safety Awareness Week is an annual recognition event intended to encourage everyone to learn more about health care safety. During this week, the Institute for Healthcare Improvement (IHI) seeks to advance important discussions locally and globally, and inspire action to improve the safety of the health care system — for patients and the workforce. During Patient Safety Awareness Week, IHI held three webinars. Watch the webinars from the links below.
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News Article
Baby died after deadly bowel condition was mistaken for cow’s milk allergy
Patient Safety Learning posted a news article in News
A two-month-old baby died after doctors mistook symptoms of a suspected perforated bowel for a cow’s milk intolerance. Nailah Ally was diagnosed with a hole in the heart before she was born and necrotising enterocolitis (NEC) shortly after her birth in October 2019. Nailah died from multiple organ failure after she was sent home from hospital and went into septic shock A consultant believed Nailah might have an intolerance to cow’s milk and changed the formula she was being fed. A spokesman for the family said: “Nailah’s case not only vividly highlights the dangers of sepsis, but the potential consequences of poor communication between doctors as well as between doctors and families.” Read full story (paywalled) Source: The Telegraph, 7 March 2023 -
Content ArticleThis video published by the Irish Health Service Executive (HSE) tells the story of Pat, whose bowel cancer diagnosis was missed, resulting in his premature death. His daughter Patricia talks about the two investigations that took place into her father's death and how the hospital's internal investigation failed to acknowledge that a staff member had raised concerns about Pat's initial colonoscopy on five occasions, but this had not been followed up. She describes the impact of these events on her father and the rest of the family and calls on medical professionals to "trust us (families) more and fear solicitors less."
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Content ArticleIn November 2021, 15-year old Alice Tapper nearly died due to a missed diagnoses of a perforated appendix. In this opinion piece, Alice shares her experience of being admitted to hospital with intense abdominal pain and other serious symptoms. In spite of her parents' requests for imaging to rule out appendicitis, doctors diagnosed that Alice had a viral infection and refused to prescribe antibiotics. Alice's condition severely deteriorated, leading her father to call the hospital and beg a gastroenterologist for further investigation. Fortunately, the hospital granted his request and after an x-ray and ultrasound, Alice was found to have a perforated appendix. She was going into hypovolemic shock, when severe blood or other fluid loss makes the heart unable to pump enough blood to the body. Thankfully, emergency surgery and antibiotics saved Alice's life, but she reflects on the fact that without her father's intervention, she would probably have died. She describes how her doctors failed to take the concerns she and her parents repeatedly expressed seriously, and that this lack of responsiveness could have been fatal. She highlights research that shows that appendicitis is missed in up to 15% of paediatric patients, and that missed diagnosis is most common in children under five, and is more common in girls than boys.
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Content Article
In a blog for National Voices, the leading coalition of health and social care charities in England, Patient Safety Learning’s Chief Executive Helen Hughes discusses an independent report written by risk expert Tim Edwards that highlights serious and widespread safety concerns around the misdiagnosis of pulmonary embolism. -
Content ArticleIn this blog for the Citizens Commission on Human Rights, Jane London shares her account of how electroconvulsive therapy (ECT) has affected her life since early adulthood, resulting in severe memory loss and heart problems. Jane shares how her physical medical problems including appendicitis and a severe heart attack were put down to depression, and how she was nearly forced to have ECT against her will in England in 1966. When her abusive marriage ended in 1968 and Jane returned to Australia her mother insisted she have ECT, despite her depression being temporary and related to her marriage ending. After 14 treatments, Jane left the treatment facility and received talking therapy to help her recover. Jane talks about the dramatic adverse effect ECT has had on the rest of her adult life.
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Content Article
Tim Edwards is a risk management expert and son of Jenny, who passed away in February 2022 from pulmonary embolism (PE), following a misdiagnosis. Frustrated by the quality of the initial investigation that followed her death and the lack of assurance that learning would take place, Tim conducted an independent review: Independent review of pulmonary embolism fatalities in England & Wales – recent trends, excess deaths, their causes and risk management concerns. Drawing on existing data, freedom of information requests and Jenny’s case, the report raises significant patient safety concerns relating to PE care across England and Wales. Tim calculated that from April 2021 to March 2022, there was a minimum of 400 excess deaths due to pulmonary embolism misdiagnosis. In this opinion piece, Tim draws on his research to highlight the key patient safety issues, and to encourage further dialogue around the topic. -
Content ArticleElizabeth Holmes, the 38 year old founder of failed diagnostic start-up Theranos, was sentenced to more than 11 years in prison this November. The sentence was handed down nearly a year after she was found guilty of defrauding investors about her finger prick blood testing devices, and seven years after the Wall Street Journal published its first investigation exposing the company’s struggles. Theranos’ customers received false laboratory test results indicating life threatening conditions such as cancer and HIV. Patients were left to wait anxiously while traditional laboratories repeated the tests, and at least one customer stopped taking his medication on the basis of erroneous results. Holmes was ultimately not convicted of charges relating to patient harm, instead she will be locked up for misleading wealthy investors.
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News Article
ER doctors in the US misdiagnose patients with unusual symptoms
Patient Safety Learning posted a news article in News
As many as 250,000 people die every year because they are misdiagnosed in the emergency room, with doctors failing to identify serious medical conditions like stroke, sepsis and pneumonia, according to a new analysis from the US federal government. The study by the Agency for Healthcare Research and Quality estimates roughly 7.4 million people are inaccurately diagnosed of the 130 million annual visits to hospital emergency departments in the United States. Some 370,000 patients may suffer serious harm as a result. Researchers from Johns Hopkins University analysed data from two decades’ worth of studies to quantify the rate of diagnostic errors in the emergency room and identify serious conditions where doctors are most likely to make a mistake. While these errors remain relatively rare, they are most likely to occur when someone presents with symptoms that are not typical. “This is the elephant in the room no one is paying attention to,” said Dr. David E. Newman-Toker, a neurologist at Johns Hopkins University and director of its Armstrong Institute Center for Diagnostic Excellence, and one of the study’s authors. The findings underscore the need to look harder at where errors are being made and the medical training, technology and support that could help doctors avoid them, Dr. Newman-Toker said. “It’s not about laying the blame on the feet of emergency room physicians,” he said. Read full story Source: New York Times, 15 December 2022 -
Content ArticleDiagnostic errors are a known patient safety concern across all clinical settings, including the emergency department (ED). The authors from the John Hopkins University conducted a systematic review to determine the most frequent diseases and clinical presentations associated with diagnostic errors (and resulting harms) in the ED, measured error and harm frequency, as well as assessing causal factors.
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News Article
Strep A: Parents say son misdiagnosed before death
Patient Safety Learning posted a news article in News
The family of a boy who died of an invasive form of strep A have said they sought medical help three times before he was admitted to hospital. Jax Albert Jefferys, who attended Morelands Primary School in Waterlooville, Hampshire, died on 1 December, aged five. His family said they were initially told he had flu. Since September, UK Health Security Agency figures show 15 UK children have died after invasive strep A infections. Paying tribute to their "darling son", Jax's family said they had sought medical advice on three occasions during the four days leading up to his death and were told that he was suffering with influenza A. "We then followed the recommended course of action: to administer a proprietary paracetamol-based medication in the prescribed dosage," they said in a statement. However, they said on the fourth day Jax's condition "deteriorated so much" they "rushed him to hospital" and he later died. "Only after his death was it confirmed that the cause was [strep A]," the family said. Read full story Source: BBC News, 14 December 2022 -
Content Article
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Jenny Edwards died in February 2022 from pulmonary embolism, following misdiagnosis. In this blog, her son Tim introduces us to Jenny, illustrating the deep loss felt following her premature passing. He talks about the care she received and argues that there were multiple points at which pulmonary embolism should have been suspected. Tim found the investigation that followed Jenny’s death to be lacking in objectivity and assurance that any learning could be taken forward. He has since produced an independent report, drawing on existing data, freedom of information requests and his mother’s case, to highlight broader safety issues.- Posted
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Content Article
Pulmonary embolism is the third most common cause of cardiovascular death worldwide after stroke and heart attack. Although life-threatening, when diagnosed promptly survival rates are good. This report, authored by risk expert Tim Edwards and published by Patient Safety Learning, highlights serious and widespread patient safety concerns relating to the misdiagnosis of pulmonary embolisms. Drawing on existing data, freedom of information requests and his mother’s case, he outlines nine calls for action to improve pulmonary embolism care. -
Content ArticleThis article by Rebecca Rosen and Trisha Greenhalgh in the BMJ looks at the safety of remote GP consultations. It begins by looking at the case of student David Nash, who tragically died in 2020 after four telephone consultations with his GP; he was denied an in-person appointment for a painful ear infection that led to a fatal brain abscess. One coroner has raised concerns that this is not a one-off incident, noting that in five inquest reports they wrote during the pandemic, they question whether deaths could have been prevented by in-person consultations. The authors look at the recommendations of the ongoing 'Remote by Default 2' study, which is exploring how best to embed remote consulting in future GP services. They highlight better triage of appointment requests, active listening, checking back, increasing the use of video consulting and better training for clinicians as factors that could improve the safety of remote consultation.
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Content ArticleIn July 2022, HSIB launched a national investigation into the safety risk of clinical investigation booking systems failures. Specifically, the investigation explores the use of paper or hybrid booking systems and the production of appointment letters. This interim bulletin highlights a safety risk identified by the investigation and presents a safety observation for the attention of NHS care providers. Some vital NHS services still use paper-based or hybrid systems, which may have been developed over time and could leave unintended gaps where patients can be lost in the system. The reference case for this investigation is the experience of a patient whose magnetic resonance imaging (MRI) scan was not rescheduled following a cancellation, leading to a delay in the diagnosis of cancer. Hybrid systems were in use, which did not assist staff to keep track of patients. Additionally, the hybrid systems in use did not allow appointment letters in non-English languages to be produced.
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Content ArticleThis article in Time reviews the documentary film 'To Err is Human', which explores the tragic outcomes of medical errors and the medical culture that allows them to persist. The film follows the Sheridans, a family from Boise, Idaho on their journey to understand how two major medical errors befell their family: one that contributed to a case of cerebral palsy, and another that involved a delayed cancer diagnosis and ended in death.
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