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Showing results for tags 'Diagnostic error'.
Found 148 results
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News Article
Probe after man wrongly diagnosed with Alzheimer's disease
Patient Safety Learning posted a news article in News
A hospital trust is investigating after a patient was incorrectly diagnosed and treated for Alzheimer's disease for seven years. Alex Preston, from Anstey, Leicestershire, was 54 at the time and said the diagnosis completely destroyed his life and made him feel suicidal. Mr Preston said he was having problems concentrating at work in 2014. "The doctor thought I had low mood and anxiety," he said. Mr Preston, now 62, was sent to the Bradgate Mental Health Unit where he underwent a series of tests and was diagnosed with Alzheimer's disease. "That's when my life was completely destroyed. "As soon as we were told that diagnosis, everything me and Susan had planned just went," he said. He was then re-examined in the pandemic and told that diagnosis was a mistake. Leicestershire Partnership NHS Trust (LPT) said it was undertaking an independent review of the case. Read full story Source: BBC News, 16 May 2022 -
Content Article
Improving Diagnosis in Health Care (2015)
Patient-Safety-Learning posted an article in Diagnosis
Accurate and timely diagnosis is a key aspect of healthcare, and misdiagnosis and delayed diagnosis can have serious consequences for patients. This eBook published by the National Academies for Science, Engineering and Medicine highlights that tackling diagnostic error in healthcare is a moral, professional, and public health duty. It makes recommendations to improve the safety of diagnostic processes, outlining the need for collaboration and a widespread commitment to change among healthcare professionals, healthcare organisations, patients and their families, researchers and policy makers. -
Content ArticleThis study in JAMA Network Open aimed to investigate whether attention-deficit/hyperactivity disorder (ADHD) is over diagnosed in children and adolescents. The authors reviewed 334 published studies and found convincing evidence that ADHD is over diagnosed. They highlight that the harms associated with ADHD diagnosis may outweigh the benefits, particularly in children and young people with milder symptoms.
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Content ArticleThis article in the British Journal of General Practice aimed to develop a safety-netting intervention to reduce delays in cancer diagnosis in primary care. To develop the tool, patient representatives, GPs and nurse practitioners were invited to a series of co-design workshops. These workshops suggested the intervention format and content should incorporate visual and written communication specifying clear timelines for monitoring symptoms and when to present back. Participants also agreed that they needed to be available in paper and electronic forms, be linked to existing computer systems and be able to be delivered within a 10-minute consultation. The output of this process was the Shared Safety Net Action Plan (SSNAP), a safety-netting intervention to assist the timely diagnosis of cancer in primary care.
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Content ArticleThe Patient Safety Movement are looking for patients, family members, health workers and administrators to reach out if they have an experience related to harm or death due to a medication error in the operating room. While the specific numbers may be debated, that medication errors, while rare in the operating, could have catastrophic consequences. The Patient Safety Movement are interested in hearing your perspective concerning this issue. Please email events@patientsafetymovement.org if you have a story that you’d like to share. If you are worried about anonymity please submit your story at the link below.
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Content ArticleThis study in the Journal of Patient Safety aimed to describe the contributing factors in diagnosis-related and failure-to-monitor malpractice claims in which nurses are named the primary responsible party. It also aimed to identify actions healthcare leaders can take to enhance the role of nurses in diagnosis. The authors found that as nurses are held legally accountable for their role in diagnosis, leaders need to raise awareness across the system of the roles and responsibilities of nurses in this area. They also need to focus on enhancing nurses' diagnostic skills and knowledge.
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Content ArticleAHRQ PSNet is looking for interesting, provocative cases that illustrate key issues in patient safety such as medication errors, diagnostic errors, and adverse events that either had the potential for or resulted in patient harm. Cases from outpatient, ambulatory surgery, home health, long-term care, and rehabilitation settings are of particular interest. When a case is selected, the editorial team invites an expert author to write a commentary based on the case. Please note that case submitters do not receive any “authorship” because case submissions are anonymous. However, submitters of selected cases will receive a $300 honorarium. The AHRQ Patient Safety Network (PSNet) is a national web-based resource featuring the latest news and essential resources on patient safety.
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Content ArticleThis thesis explores different aspects of risk and safety in healthcare, adding to previous research by studying patient safety in first-contact care, primary care and the emergency department. The author investigated preventable harm and serious safety incidents in primary health care and emergency departments, and found that diagnostic error was the most common type or error. The thesis makes recommendations for safety improvements at all levels of a healthcare system.
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Content ArticleLanguage barriers, reduced self-advocacy, lower health literacy and biased care may hinder the diagnostic process. This US study in BMJ Quality & Safety looks at patient-reported diagnostic errors, what contributes to them and the impact they have, and examines the differences between respondents with limited English-language health literacy or disadvantaged socioeconomic position, and their counterparts. The authors conclude that: interpreter access should be viewed as a diagnostic safety imperative. social determinants affecting care access and affordability should be routinely addressed as part of the diagnostic process. patients and their families should be encouraged to access and update their medical records.
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Content ArticleIn this primer for Patient Safety Network, the authors examine the issues surrounding diagnostic error and delay during the Covid-19 pandemic. They discuss the following issues: Biases in the diagnostic process - availability bias, anchoring bias, implicit biases Diagnostic testing for active SARS-CoV-2 Infection Clinical implications of diagnostic error
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Content ArticleIn this article in Becker's Hospital Review, Mackenzie Bean highlights five of the most pressing safety issues for healthcare systems and hospitals to address in 2022:Foundational safety workSupporting the healthcare workforceIntegrating equity into safety workDiagnostic harmHealthcare-associated infections
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Content ArticleAn alarming statistic shared by countless people is based on a highly problematic bit of data extrapolation and has been used to paint all of medicine as untrustworthy. In this article, Jonathan Jarry explores the evidence.
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Content ArticleSerena Roberts died as the result of an ovarian cancer which was not diagnosed until her death. She was initially seen for an ultrasound scan in April 2020 having reported symptoms of recurrent very heavy vaginal bleeding, and had been recommended to be referred to a gynaecologist for review but was not referred. In November 2020 her GP marked her referral letter as urgent, but this was entered as routine on the e-referral system and did not include important risk factor details regarding her BMI. Her condition worsened and on her second admission to hospital in March 2021 she died. The Coroner in her report highlights concerns about significant delays in patients being seen in secondary care for gynaecological referrals from GPs, the understanding and application of NICE guidance on heavy premenstrual bleeding in General Practice and the documentation and processes relating to referrals to secondary care from the GP.
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Content ArticleThis article explores the use of infrared thermometers to screen for fever to detect Covid-19, and how they are not accurate enough alone to support a medical diagnosis.
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Content ArticleThis study in the journal Rheumatology looked at the experience and views of rheumatology patients and clinicians regarding telemedicine. The Covid-19 pandemic has forced a rapid transition towards telephone consultations, but there are still many research gaps in understanding the safety and acceptability of telemedicine.
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Content ArticleThis study in BMJ Quality & Safety examines how much electronic differential diagnostic support (EDS) systems improve diagnostic accuracy, and whether EDS should be used early or late in the diagnostic process. Using a volunteer sample of medical students and doctors at six Canadian medical schools, the authors compared the rate of correct diagnosis when EDS was used early and late in the diagnostic process. The study found that EDS increased the number of diagnostic hypotheses and the likelihood of correct diagnosis, and that these effects persisted whether EDS was used early or late in the diagnostic process.
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Content ArticleThis article from the Agency for Healthcare Research and Quality (AHRQ) in the United States is the transcript of a conversation between AHRQ’s Acting Director David Meyers, MD, and the Agency’s chief patient safety official, Jeff Brady, MD MPH, about key issues in diagnostic safety. Diagnostic safety is “the newest frontier in patient safety,” according to Dr Brady, who emphasises the Agency’s commitment to improve diagnostic safety and explains how researchers are working to better understand diagnostic errors and design systems and processes to reduce errors.
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Content ArticleDiagnostic errors are the number one patient safety concern in healthcare today, inflicting harm on hundreds of thousands of patients in the USA annually. The problem is complex and involves the difficulties inherent in diagnosis generally, the known weaknesses of human cognition and the myriad breakdown points in our healthcare systems. In this BMJ Editorial, Mark Graber discusses the advantages of clinical decision support tools for diagnosis (CDS-Dx) and three promising trends regarding the uptake and potential use of CDS-Dx systems. Further reading: Co-development of OurDX - an online tool to facilitate patient and family engagement in the diagnostic process
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Content ArticleThe Healthcare Safety Investigation Branch (HSIB) identified a patient safety risk caused by delays in diagnosing lung cancer. Lung cancer is the third most common cancer diagnosed in England, but accounts for the most deaths. Two-thirds of patients with lung cancer are diagnosed at an advanced stage of the disease when curative treatment is no longer possible, a fact which is reflected in some of the lowest five-year survival rates in Europe. Chest X-ray is the first test used to assess for lung cancer, but about 20% of lung cancers will be missed on X-rays. This results in delayed diagnosis that will potentially affect a patient’s prognosis. The HSIB investigation reviewed the experience of a patient who saw their GP multiple times and had three chest X-rays where the possible cancer was not identified. This resulted in an eight-month delay in diagnosis and potentially limited the patient’s treatment options.
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Content ArticleMany diagnostic mistakes are caused by reasoning errors, but lack of feedback makes it difficult for healthcare providers to make improvements in this area. This paper, published in BMJ Quality & Safety, describes the reason for and process of developing 'The Diagnosis Learning Cycle', a new model for feedback and improvement in diagnosis. The model is based on theory and knowledge from both outside and within the field of healthcare. It proposes a standardised feedback mechanism that includes concrete measures of factors such as reasoning and confidence.
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Content ArticleDiagnostic errors have a negative impact on patient treatment and cost healthcare systems a large amount in wasted resources. This paper published by the Deeble Institute for Health Policy Research looks at diagnostic errors related to medical imaging in Australian public healthcare. It also looks at health policies that have been used internationally to improve the use of diagnostic imaging and reduce the consequences of diagnostic errors. The authors recommend: implementing a national strategy in Australia to identify and prevent diagnostic errors analysing medical indemnity claims to help measure the incidence and consequences of diagnostic errors.
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Content Article
AHRQ: Toolkit for engaging patients to improve diagnostic safety
Mark Hughes posted an article in Diagnostic error
Research suggests that a key factor contributing to diagnostic errors is the breakdown of communication between patients and healthcare professionals. The Agency for Healthcare Research and Quality (AHRQ) in the United States has developed this toolkit to promote enhanced communication and information sharing between patients and healthcare professionals. It is designed to help patients, families, and health professionals work together as partners to improve diagnostic safety. -
Content ArticleDiagnostic error occurs more frequently in the emergency department than in regular in-patient hospital care. This study in BMC Emergency Medicine sought to characterise the nature of reported diagnostic error in hospital emergency departments in England and Wales from 2013 to 2015. The authors identified the priority areas for intervention to reduce the occurrence of diagnostic error. The study found that system modifications are needed to support clinicians in assessing patients and interpreting investigations. Interventions to reduce diagnostic error need to be evaluated in the emergency department setting, and could include standardised checklists, structured reporting and technological investigation improvements.
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Content ArticleThis article by the Patient Safety Network provides an overview of the impact of diagnostic errors on patient safety. It gives examples of incorrect applications of heuristics and suggests ways to overcome cognitive bias in the diagnostic process.
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Content ArticleMedical Errors: Promoting a Culture of Patient Safety is a course for continuing education relicensure requirements for Florida doctors. The purpose of this course is to promote patient safety and improving patient outcomes and is suitable for Allopathic Physicians, Osteopathic Physicians, Dentists, Podiatrists, Physician Assistants and Dietitians who are licensed in the State of Florida.
