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Showing results for tags 'Diagnostic error'.
Found 144 results
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Content ArticleMost people experience a diagnostic error at least once in their lifetime. Patients’ experiences with their diagnosis could provide important insights when setting research priorities to reduce diagnostic error. The objective of this study from Zwaan et al. was to engage patients in research agenda setting for improving diagnosis. Patients were involved in generating, discussing, prioritising, and ranking of research questions for diagnostic error reduction.
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Content ArticleThis article looks at why health journalists should be more thorough in their approach to covering news relating to diagnostic errors. Leading researchers suggest that health care providers have done little to address the problem of diagnostic errors since a seminal report was released by the Institute of Medicine in 2015 describing the widespread harms from missed and delayed diagnoses. The article looks at the issues relating to diagnosis and highlights the importance of journalists reporting on solutions as well as stories of harm. It also focuses on how health journalism can play a key role in holding healthcare organisations to account.
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Content ArticleSafety netting is a consultation technique to communicate uncertainty, provide patient information on red-flag symptoms, and plan for future appointments to ensure timely re-assessment of a patient’s condition. It is a way of managing clinical risk and helping patients identify the need to seek further medical help if their condition fails to improve, changes, or if they have concerns about their health. Former GP Professor Paul Silverston discusses the purpose of safety-netting and offers advice on a structured approach to implementing it in practice. Further reading on safety netting: Safety-netting in general practice: how to manage uncertain diagnoses Optimising GPs’ communication of advice to facilitate patients’ self-care and prompt follow-up when the diagnosis is uncertain: a realist review of ‘safety-netting’ in primary care
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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 -
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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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 -
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 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 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 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 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.
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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 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 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 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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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 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 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 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 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.
