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Found 144 results
  1. Content Article
    Diagnostic 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.
  2. Content Article
    This 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.
  3. Content Article
    The 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.  
  4. Content Article
    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.
  5. Content Article
    This 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.
  6. Content Article
    This 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.
  7. Content Article
    In 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.
  8. Content Article
    Diagnostic 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.
  9. Content Article
    Diagnostic 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. 
  10. Content Article
    This 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.
  11. 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?
  12. News Article
    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
  13. Content Article
    Diagnostic 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.
  14. Content Article
    This 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.
  15. Content Article
    The 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.
  16. News Article
    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
  17. Content Article
    Internationally, 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.
  18. News Article
    A patient was left with permanent sight loss after a hospital failed to spot the signs of a blood vessel blockage for several months. The person referred to only as Mr L, visited the emergency department at one of Wales' hospitals in January, 2018, but medics failed to consider the possibility he had suffered a watershed stroke. Details of how it took nine months before Mr L was offered a scan to consider this diagnosis have been described in a report from the Public Service Ombudsman detailing the care under Betsi Cadwaldr University Health Board. The Ombudsman, Michelle Morris, also slammed the health board for its failure to act promptly with the complaints process. She said she "cannot fail to be shocked by the fact that, although Mr L first complained to the health board in June, 2019, it took until February, 2023 for it to recognise any failings." The report details how between January and September, 2018, the health board failed to promptly and appropriately identify, investigate and treat a blockage of blood vessels in his neck (a condition called carotid artery stenosis, where the blockage restricts the blood flow to the middle of the brain, face and head). Mr L also complained that when the issue was eventually identified in September, there was a delay in getting the treatment (surgery) until November. Read full story Source: Wales Online, 2 November 2023
  19. News Article
    A woman has spoken of her "complete shock" at being misdiagnosed with cancer and undergoing surgery when she never had the condition at all. Megan Royle, 33, from East Yorkshire, was diagnosed with skin cancer in 2019. As part of her treatment, she underwent immunotherapy and her eggs were frozen due to the risk to her fertility. But after she was given the all-clear in 2021, a review showed she never had cancer and she has now won compensation from the two NHS trusts involved. Ms Royle, from Beverley, said: "You just can't really believe something like this can happen, and still to this day I've not had an explanation as to how and why it happened. "I spent two years believing I had cancer, went through all the treatment, and then was told there had been no cancer at all." "You'd think the immediate emotion would be relief and, in some sense, it was - but I'd say the greater emotions were frustration and anger." Read full story Source: BBC News, 18 October 2023
  20. News Article
    A mother of two prescribed antidepressants after complaining of fatigue was devastated when she learned she had stage four bowel cancer and had just nine months to live. Helen Canning complained of anaemia and low energy for more than a year, but as a 37-year-old with two children under the age of five, her symptoms were put down to prolonged postnatal depression and work stress. “At the end of the school day, I’d sit at my desk and lose half an hour of my time just sitting and staring,” the A-level science teacher from Suffolk said. “I was so tired. Then I would get even more stressed because I was getting behind on my work.” She went to the GP because she was concerned about her symptoms. Despite being told her iron was low, she said she was never offered a blood test to investigate this further. As well as prescribing antidepressants, the GP referred her to a gynaecologist for an ultrasound scan on her left side in December 2020, but the scan did not detect anything. But less than a year later in August 2021, she was diagnosed with bowel cancer after she was rushed into A&E with a “crippling, stabbing pain” and violent vomiting, the night before her ninth wedding anniversary. She was told she had advanced colorectal cancer, a primary tumour in the right side of her colon, with secondary growths on her ovaries, liver, and peritoneum. Though Mrs Canning was given only nine months to live after her diagnosis, the mother of two leaned on her family for strength as she started chemotherapy. It has now been over two years and she continues to fight. Now she is determined to raise awareness of the common signs and symptoms of bowel cancer, and urges people to “know their own ‘normal’ and not be afraid to keep pushing for further testing and answers when doctors don’t”. Read full story Source: Independent, 22 October 2023
  21. Content Article
    This debate was requested by Barbara Keeley MP of Worsley and Eccles South, following the death of Emily Chesterton, the daughter of her constituents Marion and Brendan Chesterton. Emily died in November 2022 after suffering a pulmonary embolism. She was just 30 years old when she died. The conclusion of the coroner was: “Emily Chesterton died from a pulmonary embolism, a natural cause of death. She attended her general practitioner surgery on the mornings of 31 October and 7 November 2022 with calf pain and shortness of breath, and was seen by the same physician associate on both occasions. She should have been immediately referred to a hospital emergency unit. If she had been on either occasion, the likelihood is that she would have been treated for pulmonary embolism and would have survived.”
  22. Content Article
    Most healthcare organisations (HCOs) find diagnostic errors hard to address. Singh et al. developed a checklist (the Safer Dx Checklist) of 10 high-priority safety practices HCOs can use to conduct a proactive risk assessment to address diagnostic error.
  23. News Article
    A mum suffered a perforated bowel and sepsis after being told she was anxious and should take constipation medication and drink peppermint tea. Farrah Moseley-Brown was in "agonising pain" after having her second son, Clay, but the hospital sent her home. Because of the delay in treating her, Ms Moseley-Brown, 28, of Barry, Vale of Glamorgan, now has a stoma. Cardiff and Vale health board admitted failures in her care and gave its "sincere apologies". Since the error, Ms Moseley-Brown has turned to TikTok to inform people about the dangers of sepsis and has had 15 million views one one video alone. She was booked into University Hospital Wales, Cardiff, for a Caesarean on 7 May 2020. After Clay was born, Ms Moseley-Brown lost about two-and-a-half pints of blood and needed further surgery to stem the bleeding. "I felt really unwell and I said this to the nurses and the staff at the hospital which they didn't listen to. They kept saying it was after-pain but it was just agonising," Ms Moseley-Brown said. Read full story Source: BBC News, 25 August 2023
  24. News Article
    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
  25. News Article
    A two-month-old baby died after doctors mistook symptoms of a suspected perforated bowel for a cow’s milk intolerance. Nailah Ally was diagnosed with a hole in the heart before she was born and necrotising enterocolitis (NEC) shortly after her birth in October 2019. Nailah died from multiple organ failure after she was sent home from hospital and went into septic shock A consultant believed Nailah might have an intolerance to cow’s milk and changed the formula she was being fed. A spokesman for the family said: “Nailah’s case not only vividly highlights the dangers of sepsis, but the potential consequences of poor communication between doctors as well as between doctors and families.” Read full story (paywalled) Source: The Telegraph, 7 March 2023
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