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Showing results for tags 'Diagnostic error'.
Found 148 results
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Content ArticleThis article describes how a radiology group in Arizona allegedly missed dozens of breast malignancies, some of which were obviously cancer. Breast surgeon Dr Beth Dupree and a team of expert radiologists identified 25 missed cancer diagnoses that required either surgery, chemotherapy, radiation or a mastectomy at Northern Arizona Healthcare between 2016 and 2018. The team felt that there was a high chance of the number of women with missed cancers being higher than those uncovered by the review, but their request to expand the investigation did not go ahead.
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Content ArticleLearning from mistakes generally is considered the upside to failure. But in healthcare, where staff members regularly face stressors and systemic issues that impede a strong culture of safety, creating that standard can be difficult. To understand why medical mistakes and care complications occur repeatedly Becker's spoke with Patricia McGaffigan, vice president of safety programmes for the Institute for Healthcare Improvement. Ms. McGaffigan outlined three factors that contribute to repeat medical errors, care complications or lost progress on quality improvement initiatives: A "whack-a-mole" approach to safety. Lack of focus on systemwide changes. Unhealthy or unsafe work environments.
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Content ArticleThe Brain Charity has launched a survey that looks into delayed and misdiagnosis of neurological conditions, with the hope that the findings will help improve the issues people with neurological conditions can face when seeking a diagnosis. The survey is open to anyone who has a neurological condition, or to family members who can complete the survey on a patient’s behalf. Follow the link below to find out more about the survey and to complete it.
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Content ArticleThis article tells the story of Mr K, who died following a misdiagnosis of tension pneumothorax. Mr K was 81 and had a history of chronic obstructive pulmonary disease (COPD) and bullous emphysema. He had been diagnosed with a bulla, a large air pocket, in his right lung. The medical team treating Mr K after his admission to hospital with shortness of breath failed to review his previous x-ray and medical notes, and did not involve the respiratory team in his treatment. This led to his misdiagnosis, after which he was fitted with an unnecessary chest drain. The drain collapsed the bulla and ruptured a blood vessel leading to progressive bleeding. The medical team did not recognise their error or Mr K's bleeding and he died two days following the insertion of the drain. At his inquest, the Coroner found that the unnecessary chest drain led to Mr K's death, and that there was a missed opportunity to reassess the situation at a review the next day. They ordered that a prevention of future death report be made as the evidence heard at the inquest revealed a number of matters that gave rise to concern.
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Content ArticleAt the start of the Covid-19 pandemic, demand on the NHS 111 system exceeded capacity and only around half of calls were answered during that time. This investigation by the Healthcare Safety Investigation Branch (HSIB) aimed to support improvements in the delivery of NHS 111 and other telephone triage services during a national healthcare emergency. HSIB first identified a potential safety risk associated with NHS 111’s response to callers with Covid-19-related symptoms when concerns were raised through HSIB’s Citizens’ Partnership. The national investigation aimed to understand: the set-up, design and delivery of the Covid-19 telephone triage service accessed by the public by dialling 111 in response to the pandemic. the context and contributory factors influencing the pathway for patients calling NHS 111 with Covid-19-related symptoms. The investigation used four real patient safety incidents involving patients and their families who dialled NHS 111 for advice during the Covid-19 pandemic. All four patients in these reference events—Vincenzo, Ali, Patrick and Dr C—died of Covid-19 having been advised by NHS 111 to stay at home.
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Content ArticleDiagnostic errors are major contributors to patient harm. Strategies to identify and analyse these events are still emerging, but several show promise for use in operational settings. The Agency for Healthcare Research and Quality (QHRQ) has developed Measure Dx to help healthcare organisations identify diagnostic safety events and gain insights for improvement. Measure Dx can be used by any healthcare organisation interested in promoting diagnostic excellence and reducing harm from diagnostic safety events. Potential users include clinicians, quality and safety professionals, risk management professionals, health system leaders, and clinical managers.
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Content ArticleHardeep Singh, an informatics leader, patient safety advocate and innovator has been awarded the Individual Achievement Award in the 20th John M. Eisenberg Patient Safety and Quality Awards for demonstrating exceptional leadership and scholarship in patient safety and healthcare quality through his substantive lifetime body of work. Eric Thomas speaks to Hardeep in an interview for the Joint Commission Journal on Quality and Patient Safety.
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News Article
Leapfrog Group will measure US hospitals on diagnostic performance in 2024
Patient Safety Learning posted a news article in News
The Leapfrog Group will add a section to its annual survey in 2024 asking US hospitals to report their progress on evidence-based practices designed to prevent and reduce patient injury and death from diagnostic error and delay. This Autumn, Leapfrog will pilot test survey questions about a range of diagnostic practices from holding leaders accountable for diagnostic safety to openly communicating diagnostic errors to patients and optimising electronic records to support accurate and timely diagnosis. Results of the Leapfrog Hospital Survey — completed voluntarily each year by more than 2,300 U.S. hospitals — rate participants’ progress toward Leapfrog’s standards for safety, quality and transparency and are publicly reported. Since 2000, the survey has been the centerpiece of Leapfrog’s mission to “support informed health care decisions and promote high-value care.” The results are also used by hospitals to benchmark their performance to others in the industry. The addition to the survery is part of a larger push to reduce harm caused by diagnostic error. Leapfrog is working with the Society to Improve Diagnosis in Medicine (SIDM) on a multi-year project called “Recognizing Excellence in Diagnosis.” Mark L. Graber, SIDM’s Founder and President Emeritus, expects that including diagnosis in the survey will elevate organizations’ interest in addressing diagnostic error. “Healthcare organizations need to address the harm arising from diagnostic error in their own hospitals.” says Dr. Graber. “The new Leapfrog report gives them ideas on where to start.” Read full story Source: Betsey Lehman Center, 14 September 2022 -
Content ArticleIn this blog for Psychology Today, Gary Klein looks at the psychological causes of diagnostic errors, arguing that being clear about the exact causes of these errors is the only way to reduce them. Drawing on physical causes of diagnostic error identified in an Institute of Medicine report in 2015, he highlights the need to go further in understanding the explanations the report offers for diagnostic errors.
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Content ArticleThis blog describes the experience of Colonel Steven Coffee, Cofounder of Patients for Patient Safety US, who experienced a series of medical errors following the birth of his son. After a missed diagnosis of galactosemia, his son suffered liver failure and underwent a liver transplant at eight weeks old. Following his operation, the hospital where he was being treated did not have access to the powdered soy milk which was essential for his son's recovery. This experience spurred Colonel Coffee on to become an advocate for patient quality and safety in health care. For the last nine years, he has worked toward improved patient safety as the first community chair of MedStar Health’s Patient and Family Advisory Council for Quality and Safety (PFACQ).
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Content ArticleTo improve their diagnosis and management skills, doctors need consistent, timely and accurate feedback, as it helps them become better calibrated, leading to more appropriate clinical decisions. Despite its benefits, clinicians do not consistently receive information on the subsequent clinical outcomes of patients they have diagnosed and treated, known as patient outcome feedback. This paper discusses challenges faced in developing systems for effective patient outcome feedback. The authors propose applying a sociotechnical approach using health IT to support these systems. The concepts they discuss are applicable not only to fragmented systems of care, but also to integrated health systems that plan to harness the benefits of integration for providing effective clinician feedback.
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Content ArticleReducing errors in diagnosis is the next big challenge for patient safety. This article highlights ways in which healthcare organisations can pursue learning and exploration of diagnostic excellence (LEDE). Building on current evidence and their recent experiences in developing such a learning organisation at Geisinger in Pennsylvania, the authors propose a 5-point action plan and corresponding policy levers to support the development of LEDE organisations.
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Content ArticleThis infographic accompanies the TeamSTEPPS for diagnosis improvement course from the US Agency for Healthcare Research and Quality (AHRQ).
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Content Article
AHRQ course- TeamSTEPPS® for diagnosis improvement
Patient-Safety-Learning posted an article in Diagnosis
Diagnostic harm is an area of concern in healthcare quality and patient safety. A growing body of patient safety and care delivery research shows that diagnostic harm is both widespread and costly. TeamSTEPPS is an evidence-based program built on a framework composed of four teachable, learnable skills—communication, leadership, situation monitoring and mutual support. The TeamSTEPPS for Diagnosis Improvement Course applies the TeamSTEPPS framework to the specific problem of diagnostic error. On the course. teams will learn about how improved communication among all members of the team can help lead to safer, more accurate and more timely diagnosis in all healthcare settings. The course can be delivered virtually, in a classroom setting or as individual self-paced learning modules. Additional resources for trainees include: Team assessment tool for improving diagnosis Case study of the diagnostic journey of Mr. Kane Reflective practice tool Postcourse knowledge assessment -
Content ArticleBabylon is a US company that offers AI-powered online apps to health systems. Several UK hospital trusts have used Babylon apps to triage patients and reduce attendances at accident and emergency departments since 2018. In this blog, Nicole Kobie, contributing editor at technology website Wired, looks at Babylon's recent cancellation of its last contract with an NHS trust. She highlights that although some welcome Babylon's exit from the NHS, the disruption caused by the apps' implementation was costly and has left some trusts with large bills. The apps also triggered complaints from the Medicines and Healthcare products Regulatory Agency (MHRA) after concerns that Babylon's AI was missing signs of serious illness. The article highlights the need to carefully consider patient safety and cost-effectiveness when introducing new technologies into health systems, and take a slower approach to rolling out AI innovations.
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Content ArticleDefining whether a diagnostic error has occurred can be difficult, but in order to reduce harms from diagnostic errors, hospitalists must first understand how these errors occur and then develop practical strategies to avoid them. This article in the journal Annals of Internal Medicine explores these issues and highlights new opportunities for reducing diagnostic error in hospitals.
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Content ArticleThe fishbone diagram is a widely-used patient safety tool that helps to facilitate root cause analysis discussions. The authors of this article in the journal Diagnosis expanded this tool to reflect how both systems errors and individual cognitive errors contribute to diagnostic errors. They describe how two medical centres in the US have applied this modified fishbone diagram to approach diagnostic errors in a way that better meets their patient safety and educational needs.
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Content ArticleAlcoholism, more professionally termed alcohol use disorder (AUD), is a widespread and costly behavioural health condition. The aims of this paper from Zipperer et al. are draw attention to systemic gaps in care for patients with AUD and advocate for patient safety leaders to partner with both the mainstream medical and substance abuse treatment communities to reduce harm in this patient population.
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Content ArticleThis article outlines the results of a recent investigation by the Parliamentary and Health Service Ombudsman (PHSO) which found that a 65-year-old man died after doctors failed to notice serious abnormalities on his X-ray. The patient, known as Mr B, was admitted to University Hospitals Birmingham NHS Foundation Trust in May 2019 after being unwell for several days with abdominal pain and vomiting. An X-ray of his abdomen was taken, which two doctors said did not show any apparent abnormalities. The following day Mr B's condition deteriorated and he suffered a heart attack and died. The PHSO investigation found that the Trust failed to notice a blockage in his intestine on the X-ray. Because of this failure, Mr B did not receive treatment that could have saved his life.
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Content ArticleThis landmark report from the Leapfrog Group, an independent national healthcare safety watchdog in the US, is the result of an intensive year-long effort bringing together the nation’s leading experts on diagnostic excellence, including physicians, nurses, patients, health plans, and employers. Together, the multi-stakeholder group reviewed the evidence and identified 29 evidence-based actions hospitals can implement now to protect patients from harm or death due to diagnostic errors. Diagnostic errors contribute to 40,000-80,000 deaths a year, with over 250,000 Americans experiencing a diagnostic error in hospitals. This includes delayed, wrong, and missed diagnoses, and those that are not effectively communicated to the patient.
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Content ArticleThis white paper from the Institute for Healthcare Improvement (IHI) describes a framework to guide health care organisations in their efforts to provide safe, equitable, person-centred telemedicine. The framework includes six elements to consider: access, privacy, diagnostic accuracy, communication, psychological and emotional safety, and human factors and system design.
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Content ArticleHuman error plays a vital role in diagnostic errors in the emergency department. A thorough analysis of these human errors, using information-rich reports of serious adverse events (SAEs), could help to better study and understand the causes of these errors and formulate more specific recommendations. Baartmans et al. studied 23 SAE reports of diagnostic events in emergency departments of Dutch general hospitals and identified human errors. They found that the combination of different instruments and information-rich SAE reports allowed for a deeper understanding of the mechanisms underlying diagnostic error. Results indicated that errors occurred most often during the assessment and the testing phase of the diagnostic process. Most often, the errors could be classified as mistakes and violations, both intended actions. These types of errors are in need of different recommendations for improvement, as mistakes are often knowledge based, whereas violations often happen because of work and time pressure. These analyses provided valuable insights for more overarching recommendations to improve diagnostic safety and would be recommended to use in future research and analysis of (serious) adverse events.
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Content ArticleThe Belfast Health Trust failed to intervene quickly enough in the practice of a doctor which led to Northern Ireland's largest ever patient recall, the Independent Neurology Inquiry has found. More than 5,000 former patients of neurologist Michael Watt were invited to have their cases examined for possible misdiagnoses. Among the conditions being treated were stroke, Parkinson's disease and multiple sclerosis (MS). The inquiry found "numerous failures". The Independent Neurology Inquiry concluded that the combined effect of the failures ensured that patterns in the consultant's work were missed for a decade.
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Content ArticleThis practice pointer in The BMJ explains why diagnostic errors occur and provides five strategies that healthcare workers can use to achieve diagnostic excellence. Each of these strategies is explored in detail: Seek diagnostic feedback, which includes tracking patient outcomes and seeking feedback from patients, families and other healthcare workers. "Byte sized" learning, which involves digital learning activities. Consider bias by getting to know patients and treating them as individuals, and through taking a 'diagnostic pause' to consider whether bias is playing into decisions. Make diagnosis a team sport through multidisciplinary huddles that include healthcare workers from different professions. Foster critical thinking by using intentional strategies to foster reflective scepticism and regular review.
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Content ArticleThis study in The Joint Commission Journal on Quality and Patient Safety aimed to investigate factors affecting length of time to diagnosis in primary care in the USA. The authors found that patients presenting with new or unresolved problems in ambulatory primary care often remain undiagnosed after a year. There were no provider or patient-level variables associated with lack of diagnosis and further research is needed into the causes and consequences of lack of timely diagnosis.
