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Showing results for tags 'Diagnostic error'.
Found 145 results
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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 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 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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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 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 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 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 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 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 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. -
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 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 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 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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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 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.
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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 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 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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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 -
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.
