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Showing results for tags 'Diagnostic error'.
Found 152 results
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Content ArticleThis report commissioned by the US Agency for Healthcare Research and Quality aims to identify major themes related to the current state of diagnostic safety and highlight key gaps in knowledge. Through a rapid narrative review methodology to evaluate multiple resources in the literature and interviews with experts, it presents several findings that have implications for future resource investments to reduce harm from diagnostic errors. The report looks at the following key themes: Incidence and Contributing Factors Measurement: Data and Methods Cognitive Processes Culture, Workflow, and Work System Issues Disparities Health Information Technology Patients and Families Testing Interventions Implementation
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Content ArticleKerri Mothersole was a 44 year old woman who had a past medical history of asthma, labyrinthitis, depression and back pain. In May 2020 she was seen with symptoms of possible early menopause and blood tests requested. In October 2020 she was noted to be suffering from tiredness and had irregular periods and again blood tests were requested. Blood tests taken in January 2021 noted a low haemoglobin and ferritin so iron was prescribed as well as follow up in two months. In March 2021 she complained of having per vaginal bleeding for six weeks and she was referred for an ultrasound. Due to her underlying ill health, she had difficulty in attending appointments and missed a number of different appointments. She was seen in the surgery on 21 June 2021 by her General Practitioner who noted abdominal tenderness and weight loss and he again referred her for an ultrasound. An ultrasound was undertaken by a private firm HEM Clinical Ultrasound on 28 June 2021 but the report was never sent to her General Practitioner. A second ultrasound on the 1 July 2021suggested a diagnosis of adenomyosis but noting that serious pathology could not be ruled out. Only the second report was sent to the General Practitioner which led to a routine gynaecology referral, she had however already been referred to the colorectal team on the urgent two week wait pathway. Had the earlier scan report been seen this would have led to an urgent referral to gynaecology. There were a number of missed appointments and a colonoscopy took place on 20 October 2021. The procedure was negative but the endoscopist thought he could feel something in the pelvis and a CT scan was arranged. The CT scan on 28 October 2021 demonstrated a large pelvic mass and she was referred to the gynaecology team in early December and a multidisciplinary team meeting discussion on 17 December 2021 led to a request for an MRI scan. Appointments were made for 31 December 2021, 25 January 2022 and again in February but not attended and she eventually underwent an MRI on 1 May 2022 which revealed a large mass. She was again discussed at the multidisciplinary team meeting on 6 May 2022 and referred to the gynae-oncology surgeons at Maidstone hospital. She was seen on 1 June 2022 and booked for surgery on 27 June 2022. She was, however, far too unwell for surgery on 27 June 2022 and further investigations revealed brain metastases. She was admitted to hospital and treated with steroids and referred to the Oncologists as surgery was deemed no longer appropriate. She was prescribed hormone treatment but she was, by now, too unwell to receive even palliative radiotherapy. She was taken to Medway Maritime hospital on 19 August 2022 and was struggling as she had been so unwell at home. Whilst plans were being made to provide some care at home she remained overnight but sadly died on 20 August 2022 as she was so unwell she could not return home.
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Content Article
Diagnostic error in mental health: a review (4 April 2024)
Mark Hughes posted an article in Diagnostic error
Diagnostic errors are associated with patient harm and suboptimal outcomes. However, despite efforts to advance definition, measurement and interventions for diagnostic error, diagnosis in mental health is not well represented in this ongoing work. The authors of this article, published in BMJ Safety & Quality, summarise the current state of research on diagnostic errors in mental health and identify opportunities to align future research with the emerging science of diagnostic safety. -
Content ArticleDespite growing awareness of diagnostic error, most healthcare systems do not track or record diagnostic quality, and many diagnostic safety events are not recognised. Without methods to identify, measure, investigate and analyse events, healthcare organisations cannot understand causes of diagnostic errors, identify contributing factors or create solutions. One of the best ways to collect information about diagnostic errors is through self-reporting by patients and healthcare professionals. This issue brief from the Agency for Healthcare Research and Quality looks at how to foster psychological safety and organisational safety culture in order to reduce harm from diagnostic error.
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News Article
Hospitals grapple with radiologist shortage
Patient-Safety-Learning posted a news article in News
Increased reliance on imaging for diagnosis and efficient patient care mixed with higher volumes of patients has left US hospitals scrambling to meet demand with the few radiologists they have. There are over 1,400 vacant radiologist positions posted on the American College of Radiology's job board, according to a bulletin posted on its website. The total number of active radiology and diagnostic radiology physicians has dropped by 1% between 2007 and 2021, but the number of people in the U.S. per active physician in radiology grew nearly 10%, according to the Association of American Medical Colleges. An increase in the Medicare population and a declining number of people with health insurance adds to the problem. "Demand for imaging services is increasing across the country, creating longer worklists for radiology staff at the same time the healthcare system is experiencing a workforce shortage in radiology," Michigan Hospital Association CEO Brian Peters told The Detroit News in an April 28 report. "The combination of vacancies and increased demand can force imaging delays measured from days to upwards of two weeks." CMS also cut fees for both diagnostic (3%) and interventional radiology (4%) this year, according to an article published on healthcare technology company XiFin's website. This leaves many hospitals having to use external groups to stay on top of demand. Mr. Peters told Detroit News, "Hospitals and health systems are also competing with practices offering remote-only positions, which allows Michigan radiologists to work for out-of-state providers at higher rates." Read full story Source: Becker's Hospital Review, 29 April 2024 -
Content ArticleThis article tells the story of 61 year-old Susannah Constantine who was diagnosed with a rare neurological condition after her MRI was not looked at by her GP surgery for over a year. Susannah decided to have a private MRI when doctors couldn't diagnose why she’d been suffering from tinnitus and pins and needles in the fingers of her left hand. The results were sent to her GP, and Susannah heard no more, so struggled on for another year—she gradually became weaker and her muscles atrophied. She called her GP surgery to check if the MRI held any clues and learnt no one there had ever looked at the results—they had just been sat there for a year. She was told she needed to see a neurosurgeon immediately and was diagnosed with arteriovenous malformation (AVM), a rare neurological condition that disrupts the flow of blood and oxygen to the brain. If not spotted and treated in good time there is a one in three chance of suffering a brain haemorrhage, paralysis or stroke.
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Content Article
Improving diagnosis in health care (2015)
Patient-Safety-Learning posted an article in Diagnosis
This report is a continuation of the landmark Institute of Medicine reports To Err Is Human (2000) and Crossing the Quality Chasm (2001). It finds that diagnosis, and in particular the occurrence of diagnostic errors, has been largely unappreciated in efforts to improve the quality and safety of healthcare. Without a dedicated focus on improving diagnosis, diagnostic errors will likely worsen as the delivery of health care and the diagnostic process continue to increase in complexity. Just as the diagnostic process is a collaborative activity, improving diagnosis will require collaboration and a widespread commitment to change among health care professionals, healthcare organisations, patients and their families, researchers and policy makers. The report's recommendations contribute to the growing momentum for change in this crucial area of healthcare quality and safety. -
Content ArticleThe use of checklists as a tool to improve performance has proven successful in a variety of healthcare settings. For instance, checklists have been successful in preventing hospital-acquired infections and preventing errors in the surgical process. The use of checklists has also been recommended as a tool to reduce diagnostic errors. Diagnostic errors are frequent and often have severe consequences but have received little attention in the field of patient safety. Checklists are considered a promising intervention for the area of diagnosis because they can support clinicians in their diagnostic decision making by helping them take correct diagnostic steps and ensuring that possible diagnoses are not overlooked. This Agency for Health Research and Quality (AHRQ) issue brief summarises current evidence on using checklists to improve diagnostic reasoning.
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Content ArticleDiagnostic errors cause substantial preventable harms worldwide, but rigorous estimates for total burden are lacking. Newman-Toker and colleague previously estimated diagnostic error and serious harm rates for key dangerous diseases in major disease categories and validated plausible ranges using clinical experts. In this study they estimated the annual US burden of serious misdiagnosis-related harms (permanent morbidity, mortality) by combining prior results with rigorous estimates of disease incidence. They found that an estimated 795 000 Americans become permanently disabled or die annually across care settings because dangerous diseases are misdiagnosed. Just 15 diseases account for about half of all serious harms, so the problem may be more tractable than previously imagined.
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Content ArticleThis research letter in JAMA Internal Medicine describes a multicentre retrospective cohort study that investigated associations between stigmatising language, errors in the diagnostic process and demographics for hospitalised patients. The study found that stigmatising language in patient documentation was associated with diagnostic error and multiple diagnostic process errors. The prevalence of stigmatising language was higher in documentation relating to Black patients and patients with housing instability. The authors argue that this may be indicative of clinician biases that interfere with data gathering, communication and clinical reasoning. They call for further research to explore the mechanisms behind this and to understand how clinician use of stigmatising language can be reduced.
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Content ArticleThe US Leapfrog Group has released Recognizing excellence in diagnosis: Leapfrog’s national pilot survey report, which analyses responses from 95 hospitals on their implementation of recommended practices to address diagnostic errors, defined as delayed, wrong or missed diagnoses or diagnoses not effectively communicated to the patient or family. The National Academy of Medicine has warned that virtually every American will suffer the consequences of a diagnostic error at least once in their lifetime and noted that 250,000 hospital inpatients will experience a diagnostic error every year. While progress varies considerably, more than 60% of hospitals responded that they were either already implementing or preparing to implement each of 29 evidence-based practices known to prevent harm from diagnostic error. The practices were identified in an earlier Leapfrog report, Recognizing excellence in diagnosis: Recommended practices for hospitals. The hospitals reported barriers to putting the practices in place that include staffing shortages and budgetary pressure.
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Content Article
World Patient Safety Day 2024
Patient Safety Learning posted an article in WHO
This year’s World Patient Safety Day on 17 September 2024 is focused on the theme “Improving diagnosis for patient safety”. This article explains the aims of the event and the areas it will cover. -
Content ArticleThis qualitative study in the Journal of Patient Safety aimed to understand the perception of dental patients who have experienced a dental diagnostic error and to identify patient-centred strategies to help reduce future occurrences. Recruiting patients via social media, the researchers conducted a screening survey, initial assessment and 67 individual patient interviews to capture the effects of misdiagnosis, missed diagnosis or delayed diagnosis on patient lives. They found that dental patients endured prolonged suffering, disease progression, unnecessary treatments and the development of new symptoms as a result of diagnostic errors. Patients believed that the following factors contributed to diagnostic errors: Poor provider communication Inadequate time with provider Lack of patient self-advocacy and health literacy. Patients suggested that future diagnostic errors could be mitigated through: improvements in provider chairside manners more detailed patient diagnostic workups improving personal self-advocacy enhanced reporting systems.
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Content ArticleThis cohort study in JAMA Network explored the incidence of and factors associated with inappropriate diagnosis of pneumonia in hospitalised patients. The results showed that older patients, those with dementia and those presenting with altered mental status had the highest risk of being inappropriately diagnosed. For those who were inappropriately diagnosed, full antibiotic duration was associated with antibiotic-associated adverse events.
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Content ArticleIn this episode, we hear from Sue Allison who blew the whistle on a Senior Radiologist within her department who repeatedly failed to diagnose women who had breast cancer at NHS Morecambe Bay Trust. She explains her battle to overturn her NDA at employment tribunal and the ‘insidious bullying’ that followed after blowing the whistle on concerns about patient safety. She is joined by Samantha Prosser an experienced employment law litigator from BDBF LLP who has specialist experience in advising private and NHS consultants from leading hospitals on private and NHS whistleblowing and discrimination claims.
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Content ArticleDiagnostic errors cause significant patient harm. The clinician’s ultimate goal is to achieve diagnostic excellence in order to serve patients safely. This can be accomplished by learning from both errors and successes in patient care. However, the extent to which clinicians grow and navigate diagnostic errors and successes in patient care is poorly understood. Clinically experienced hospitalists, who have cared for numerous acutely ill patients, should have great insights from their successes and mistakes to inform others striving for excellence in patient care.
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Content ArticleDiagnostic delays in the emergency department (ED) are a serious patient safety concern. This retrospective cohort study included children treated at 954 EDs across 8 states, and examined the association between ED volume and delayed diagnosis of first-time diagnosis of an acute, serious conditions (e.g., bacterial meningitis, compartment syndrome, stroke). The researchers found that EDs with lower pediatric volume had higher rates of delayed diagnosis across 23 serious conditions.
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Content ArticleThis annual report from ECRI and the Institute for Safe Medication Practices (ISMP) presents the top 10 patient safety concerns currently confronting the healthcare industry. It is a guide for a systems approach to adopting proactive strategies and solutions to mitigate risks, improve healthcare outcomes and enhance the well-being of patients and the healthcare workforce. Drawing on ECRI and ISMP’s evidence-based research, data and insights, this report sheds light on issues that leaders should evaluate within their own institutions as potential opportunities to reduce preventable harm. Some of the concerns represent emerging risks, some are well known but still unresolved, but all of them pertain to areas where organisations can make meaningful change.
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Content Article
This is my story, as a bereaved mother, about lessons I have learnt following the unexpected death of my previously well 25-year-old daughter Gaia in University College Hospital London (UCLH) in July 2021. I have written 11 patient safety lessons in the hope this helps other families be more assertive if they have a critically sick relative in hospital. Believe me, you must be pushy to be allowed into a hospital ward, even more so ITU. I went to visit my critically sick daughter at around 10am on a Sunday morning, but was not allowed on to the ward. A senior nurse told me to GO HOME using the 'Covid' excuse. I was shut out from the bedside of my critically ill only child. I have set up TruthForGaia.com to share learnings more widely. Please take a look. I hope sharing this may contribute to reducing avoidable deaths from brain conditions which can be only too easily assumed to be intoxication, especially on weekends. I believe raised intracranial pressure (high pressure in the skull) needs more awareness and training. When will UCLH hold a medical grand round on my daughter's case?- Posted
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News Article
Hundreds of rheumatology patients wrongly prescribed drugs or misdiagnosed
Patient Safety Learning posted a news article in News
Hundreds of rheumatology patients have stopped receiving drugs they did not need or had their diagnosis changed after a damning review of the service found the standard of care was “well below” what would be considered acceptable. Jersey’s Health and Community services department has said it will be contacting some of the affected patients “over the coming weeks” and would also be seeking legal advice on “an appropriate approach to compensation”. The independent review by the Royal College of Physicians also noted there was “no evidence” of standard operating procedures for most aspects of routine rheumatological care and, in some cases, “no evidence of clinical examinations”. It also found that there had been incorrect diagnosis and wrongly prescribed drugs, describing the standard of care as “well below what the review team would consider acceptable” for a contemporary rheumatological service. The review was commissioned by HCS medical director Patrick Armstrong, following concerns raised by a junior doctor in January 2022. Read full story Source: Jersey Evening Post, 22 January 2024 -
Content ArticleDiagnostic errors contribute to patient harm, though few data exist to describe their prevalence or underlying causes among medical inpatients. The aim of this study published by Jama Internal Medicine was to determine the prevalence, underlying cause, and harms of diagnostic errors among hospitalised adults transferred to an intensive care unit (ICU) or who died. The results showed that diagnostic errors were common and associated with patient harm. Problems with choosing and interpreting tests and the processes involved with clinician assessment are high-priority areas for improvement efforts.
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Content ArticleThis study published in JAMA Internal Medicine looked at how often diagnostic errors happened in adult patients who are transferred to the intensive care unit (ICU) or die in the hospital, what causes the errors, and what are the associated harms. In this cohort study of 2428 patient records, a missed or delayed diagnosis took place in 23%, with 17% of these errors causing temporary or permanent harm to patients. The underlying diagnostic process problems with greatest effect sizes associated with diagnostic errors, and which might be an initial focus for safety improvement efforts, were faults in testing and clinical assessment.
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Content ArticleThe Care Quality Commission's (CQC) annual report on their work to enforce the Ionising Radiation (Medical Exposure) Regulations in England has been published. The regulations protect people from the dangers of being accidentally or unintentionally exposed to ionising radiation in a healthcare setting. Errors can happen when healthcare providers use ionising radiation to diagnose or treat people. Healthcare providers must notify CQC about these. The report gives a breakdown of the number and type errors that CQC was notified about between 1 April 2022 and 31 March 2023. The report also presents the key findings from our inspection and enforcement activity in that time.
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News Article
Collective intelligence can help reduce medical misdiagnoses
Patient Safety Learning posted a news article in News
An estimated 250,000 people die from preventable medical errors in the U.S. each year. Many of these errors originate during the diagnostic process. A powerful way to increase diagnostic accuracy is to combine the diagnoses of multiple diagnosticians into a collective solution. However, there has been a dearth of methods for aggregating independent diagnoses in general medical diagnostics. Researchers from the Max Planck Institute for Human Development, the Institute for Cognitive Sciences and Technologies (ISTC), and the Norwegian University of Science and Technology have therefore introduced a fully automated solution using knowledge engineering methods. The researchers tested their solution on 1,333 medical cases provided by The Human Diagnosis Project (Human Dx), each of which was independently diagnosed by 10 diagnosticians. The collective solution substantially increased diagnostic accuracy: Single diagnosticians achieved 46% accuracy, whereas pooling the decisions of 10 diagnosticians increased accuracy to 76%. Improvements occurred across medical specialties, chief complaints, and diagnosticians’ tenure levels. "Our results show the life-saving potential of tapping into the collective intelligence," says first author Ralf Kurvers. He is a senior research scientist at the Center for Adaptive Rationality of the Max Planck Institute for Human Development and his research focuses on social and collective decision making in humans and animals. Read full story Source: Digital Health News, 2 November 2023 -
Content ArticleInternationally, there is a growing awareness on diagnostic errors as a major – and too often overlooked – patient safety problem. According to analyses conducted by the Danish Society for Patient Safety, diagnostic errors are not only common, but they also have major consequences for patients and the healthcare system’s finances. In this article, Charlotte Frendved and Siri Tribler hope that by raising awareness of the diagnostic process and possible vulnerabilities can help improve patient safety.
