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Showing results for tags 'Diagnostic error'.
Found 148 results
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Content ArticleThis paper in BMJ Quality & Safety brings together the two trends of increasing focus on reducing diagnostic error, and involving patients in their care. The authors analyse strategies for patient involvement: in reducing diagnostic errors in an individual’s own care. in improving the healthcare delivery system’s diagnostic safety. in contributing to research and policy development on diagnosis-related issues.
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Content ArticleDiagnostic errors can result in avoidable harm when undiagnosed conditions remain untreated or when patients undergo unnecessary (or harmful) tests. This study seeks to estimate the incidence and origins of avoidable harm from diagnostic errors in English general practice. It defines diagnostic errors as missed opportunities to make a correct or timely diagnosis based on the evidence available. The authors conclude that although missed diagnostic opportunities (MDOs) occurred in fewer of 5% of the investigation consultations they analysed, high numbers of primary care contacts nationally suggest that several million patients are potentially at risk of avoidable harm from MDOs each year.
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Content Article
Improving diagnosis in health care (2015)
Patient-Safety-Learning posted an article in Diagnosis
This report from The National Academies of Sciences, Engineering and Medicine highlights three key themes around the issue of diagnostic error: The importance of diagnostic error in patient safety and the need to give the subject more research attention The central role that patients play in helping to avoid diagnostic error. The idea that diagnosis is a collaborative effort involving intra- and interprofessional teamwork. It also looks at several specific issues that must be addressed to reduce diagnostic errors. -
Content ArticleThis narrative review in BMJ Quality & Safety argues that being able to measure the incidence of diagnostic error is essential to enable research studies on diagnostic error and to initiate quality improvement projects aimed at reducing the risk of error and harm. It highlights three approaches that may help with measuring the incidence of diagnostic error: Using ‘trigger tools’ to identify from electronic health records cases at high risk for diagnostic error Using standardised patients (secret shoppers) to study the rate of error in practice Encouraging both patients and physicians to voluntarily report errors they encounter, and facilitating this process
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Content ArticleThis toolkit created by The National Academies of Sciences, Engineering and Medicine contains information and resources to help patients learn about and engage in the diagnostic process. There are many barriers to patients fully engaging in their diagnosis, and this toolkit aims to help patients take control of their role in the process, as well as equipping healthcare providers to create an atmosphere that allows patients to contribute meaningfully.
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News Article
Dr Michael Watt: Almost 20% of patients misdiagnosed
Patient Safety Learning posted a news article in News
Almost 20% of patients seen by neurology consultant Dr Michael Watt were given a wrong diagnosis, a report has found. A review of 927 of Dr Watt's high-risk patients found 181 people received a diagnosis described as "not secure", Health Minister Robin Swann said. He was speaking as the Belfast Trust announced the recall of a further 209 neurology patients seen and discharged by Dr Watt between 1996 and 2012. This is the third such recall. Dr Watt was at the centre of Northern Ireland's biggest patient recall linked to his work at Belfast's Royal Victoria Hospital. Mr Swann said he had met patients and families affected by the recall in October last year. "While this report is statistical in nature, it deals with individuals, their families and their experiences," he said. "I know that many will have had their confidence in our health service shaken and I remain committed to helping restore it." Read full story Source: BBC News, 20 April 2021 -
Content ArticleDiagnosis is one of the most important tasks performed by primary care doctors and the World Health Organization (WHO) has highlighted diagnostic errors in primary care as a high-priority patient safety problem. In this narrative review in BMJ Quality & Safety, the authors discuss the global significance, burden and contributory factors related to diagnostic errors in primary care.
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Content ArticleThe objective of this study from Carey et al. was to explore medical oncology outpatients' perceived experiences of errors in their cancer care. A cross-sectional survey was conducted. English-speaking medical oncology outpatients aged 18 years or older were recruited from 9 Australian cancer treatment centres. One hundred forty-eight participants perceived that an error had been made in their care, of which one third reported that the error was associated with severe harm. Of those who perceived an error had been made, less than half reported that they had received an explanation for the error and only one third reported receiving an apology or being told that steps had been taken to prevent the error from reoccurring. Patients with university or vocational level education and those who received radiotherapy or “other” treatments were significantly more likely to report an error in care. The authors concluded that here is significant scope to improve communication with patients and appropriate responses by the healthcare system after a perceived error in cancer care.
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Content ArticleThis book aims to teach the key principles of patient safety to a diverse audience: physicians, nurses, pharmacists, other healthcare providers, quality and safety professionals, risk managers, hospital administrators, and others. It is suitable for all levels of readers: from the senior physician trying to learn this new way of approaching his or her work, to the medical or nursing student, to the risk manager or hospital board member seeking to get more involved in institutional safety efforts. Understanding Patient Safety is divided into three main sections. In Section I, it describes the epidemiology of error, distinguishes safety from quality, discusses the key mental models that inform our modern understanding of the safety field, and summarises the policy environment for patient safety. In Section II, it reviews different error types, taking advantage of real cases to describe various kinds of mistakes and safety hazards, introduces new terminology, and discusses what we know about how errors happen and how they can be prevented. Although many prevention strategies will be touched on in Section II, more general issues regarding various strategies (from both individual institutional and broader policy perspectives) will be reviewed in Section III. After a concluding chapter, the Appendix includes a wide array of resources, from helpful Web sites to a patient safety glossary.
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News Article
Care home worker cancer misdiagnosis
Patient Safety Learning posted a news article in News
A care home worker who was wrongly diagnosed with cancer said she thought it was a "cruel joke" when she was told doctors had made a mistake and she did not have cancer at all. Mum-of-four Janice Johnston said her "world crumbled" when she learned she had a rare form of blood cancer at Kent and Canterbury Hospital in 2017. She had 18 months of oral chemotherapy treatment, during which she experienced weight loss, nausea and bone pain, and had to give up her job as an auxiliary nurse. When the treatment did not appear to be working, she says, medics upped the dosage. In 2018, she sought alternative treatment at Guy's Hospital in London. It was there a specialist told her she did not have cancer at all but a different condition. Mrs Johnston was awarded £75,950 in damages after East Kent Hospitals University NHS Foundation Trust admitted liability. Staff at the hospital had failed to do the necessary ultrasound scan and bone marrow biopsy before diagnosing her. Read full story Source: BBC News, 25 January 2021 -
Content ArticleHealth information technology (HIT) provides many benefits, but also facilitates certain types of errors, such as wrong-patient errors in which one patient is mistaken for another. These errors can have serious patient safety consequences and there has been significant effort to mitigate the risk of these errors through national patient safety goals, in-depth research, and the development of safety toolkits. Nonetheless, these errors persist.
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Content ArticleHealth information technology (HIT) provides many benefits, but also facilitates certain types of errors, such as wrong-patient errors in which one patient is mistaken for another. These errors can have serious patient safety consequences and there has been significant effort to mitigate the risk of these errors through national patient safety goals, in-depth research, and the development of safety toolkits. Nonetheless, these errors persist. Kim et al. analysed 1,189 patient safety event reports using a safety science and resilience engineering approach, which focuses on identifying processes to discover errors before they reach the patient so these processes can be expanded.They analysed the general care processes in which wrong-patient errors occurred, the clinical process step during which the error occurred and was discovered, and whether the error reached the patient. For those errors that reached the patient, they analysed the impact on the patient, and for those that did not reach the patient, they analysed how the error was caught.
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Content Article
Implementation Approaches for Closing the Loop (2019)
Patient-Safety-Learning posted an article in Diagnostic error
Delayed, missed and incorrect diagnoses are common causes of errors that result in patient harm and inappropriate care. However, some diagnostic errors may be avoided by effectively using health information technology. These resources from the Emergency Care Research Institute provide information on how to implement IT processes to close the loop on diagnostic evaluations. -
News Article
Incorrect covid tests spark harm review for staff and patients
Patient Safety Learning posted a news article in News
Trusts are carrying out harm reviews after a ‘contamination issue’ affecting hundreds of samples resulted in some staff and patients being wrongly told they had coronavirus, HSJ can reveal. The error happened in mid-October and involved swabs from five trusts in the South East region, which were being processed by the NHS-run Berkshire and Surrey Pathology Services. HSJ understands it is thought that around 100 people across several trusts were given false positive results, and subsequently tested negative. The trusts involved are the Royal Surrey Foundation Trust, Frimley Health Foundation Trust, Royal Berkshire Foundation Trust, Ashford and St Peter’s Hospitals Foundation Trust and Berkshire Healthcare Foundation Trust. Frimley has completed a clinical review and found no harm had been caused, while Royal Berkshire, Ashford and St Peter’s and the Royal Surrey have reviews ongoing. The position for Berkshire Healthcare, a mental health trust, is not known. Read full story (paywalled) Source: HSJ, 2 December 2020 -
Content ArticleAs we seek to develop a national healthcare system that delivers true 21st century care, we are confronted by a COVID-19 pandemic that has identified numerous challenges. Among the most important: the need to provide correct diagnoses. Definitive answers about diagnosis are critical not only for patients, but also for their families and others around them. Consequential questions gnaw at us: Are we diagnosing COVID-19 correctly? Are we missing cases? How do we know? How can we improve? Gopal Khanna and Jeff Brady are hopeful that some of the changes that have resulted from the US's battle against the pandemic will spark the long-term improvements in diagnostic safety that will strengthen the system’s ability to address COVID-19 and other challenges we face.
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Content ArticleThe US National Quality Forum (NQF) convened a multistakeholder committee to identify recommendations for the practical application of the Diagnostic Process and Outcomes domain of the 2017 Diagnostic Quality and Safety Measurement Framework, measuring and reducing diagnostic error, and measuring and improving patient safety. This report outlines the recommendations through a series of four Use Cases – missed subtle clinical findings (Use Case 1), communication failures (Use Case 2), information overload (Use Case 3), and dismissed patients (Use Case 4) – that depict resolutions to specific types of diagnostic errors, and broad-scope, comprehensive recommendations with applications to multiple populations and settings.
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News ArticleIn ‘Invisible Women: Exposing Data Bias in a World Designed For Men’ author Caroline Criado Perez writes about Rachael, a woman who suffered years of severe and incapacitating pain during her period. It takes, on average, eight years for women in the UK to obtain a diagnoses of endometriosis. In fact, for over a decade, there has been no improvement in diagnostic times for women living with the debilitating condition. You might think, given the difficulty so many women experience in having their symptoms translated into a diagnosis, that endometriosis is a rare condition that doctors perhaps don’t encounter all that often. Yet it is something that affects one in ten women – so what is going wrong? Read the full article here in The Scotsman
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Content Article
Medical error prevention (5 May 2020)
Sam posted an article in Good practice
Medical errors are a serious public health problem and a leading cause of death in the United States. It is a difficult problem as it is challenging to uncover a consistent cause of errors and, even if found, to provide a consistent viable solution that minimises the chances of a recurrent event. By recognising untoward events occur, learning from them, and working toward preventing them, patient safety can be improved. Part of the solution is to maintain a culture that works toward recognising safety challenges and implementing viable solutions rather than harboring a culture of blame, shame, and punishment. Healthcare organisations need to establish a culture of safety that focuses on system improvement by viewing medical errors as challenges that must be overcome. All individuals on the healthcare team must play a role in making the provision of healthcare safer for patients and healthcare workers. -
Content ArticleAuthors of this editorial, published in BMJ Quality & Safety, discuss the significance of the results of two new studies on hospital medicine and implications for emerging research and practice improvement efforts. The first study was a systematic review to determine the prevalence of harmful diagnostic errors in hospitalised patients. The second studied readmitted patients using established methods for diagnostic error detection and analysis to gain insights into contributing factors. Both studies advance the science of measurement and understanding of how to reduce diagnostic error in hospitals.
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Content ArticleBy understanding how physicians make clinical decisions, and examining how errors due to cognitive biases occur, cognitive bias awareness training and debiasing strategies may be developed to decrease diagnostic errors and patient harm. Studies of the impact of teaching critical thinking skills have mixed results but are limited by methodological problems. The authors of this paper, published in Academic Medicine, argue that explicit instruction in metacognition in medical education, including awareness of cognitive biases, has the potential to reduce diagnostic errors and thus improve patient safety.
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Content ArticleIn the area of patient safety, recent attention has focused on diagnostic error. The reduction of diagnostic error is an important goal because of its associated morbidity and potential preventability. A critical subset of diagnostic errors arises through cognitive errors, especially those associated with failures in perception, failed heuristics, and biases; collectively, these have been referred to as cognitive dispositions to respond (CDRs). The author of this paper, published by Academic Medicine, provides an extensive list of CDRs and a list of strategies to reduce diagnostic errors.
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Content ArticleAuthors of this journal piece, published by The American Journal of Medicine, present a comprehensive review of the available literature and current thinking related to diagnostic error. The review covers the incidence and impact of diagnostic error, data on physician overconfidence as a contributing cause of errors, strategies to improve the accuracy of diagnostic decision making, and recommendations for future research.
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Content ArticleWithin the research community, there is no consensus on the definition of diagnostic error, in part due to the complexity of diagnosis. This paper, published by Diagnosis, looks at the challenges in defining and measuring diagnostic error.
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Content Article
As college students return, a crisis in campus care awaits
lzipperer posted an article in Coronavirus (COVID-19)
Health services in college and university campuses are under pressure to respond to COVID-19 with patient safety in mind. This article from Abelson et al. in The Seattle Times discusses weakness in university health services that undermine their ability to do so. It shares interviews with students that discuss misdiagnosis and diagnostic delays due to the impact of the pandemic. -
Content ArticleJerome Groopman is a doctor who discovered that he needed a doctor. When his hand was hurt, he went to six prominent surgeons and got four different opinions about what was wrong. Groopman was advised to have unnecessary surgery and got a seemingly made-up diagnosis for a nonexistent condition. Groopman, who holds a chair in medicine at Harvard Medical School, eventually found a doctor who helped. But he didn't stop wondering about why those other doctors made the wrong diagnoses. You can listed or read his interview from the link below.
