Analysis of 583 Physician-Reported Errors (original) (raw)
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Diagnostic error in medicine: analysis of 583 physician-reported errors
Archives of internal medicine, 2009
Missed or delayed diagnoses are a common but understudied area in patient safety research. To better understand the types, causes, and prevention of such errors, we surveyed clinicians to solicit perceived cases of missed and delayed diagnoses. A 6-item written survey was administered at 20 grand rounds presentations across the United States and by mail at 2 collaborating institutions. Respondents were asked to report 3 cases of diagnostic errors and to describe their perceived causes, seriousness, and frequency. A total of 669 cases were reported by 310 clinicians from 22 institutions. After cases without diagnostic errors or lacking sufficient details were excluded, 583 remained. Of these, 162 errors (28%) were rated as major, 241 (41%) as moderate, and 180 (31%) as minor or insignificant. The most common missed or delayed diagnoses were pulmonary embolism (26 cases [4.5% of total]), drug reactions or overdose (26 cases [4.5%]), lung cancer (23 cases [3.9%]), colorectal cancer (19...
Archives of Internal Medicine, 2009
Background: Missed or delayed diagnoses are a common but understudied area in patient safety research. To better understand the types, causes, and prevention of such errors, we surveyed clinicians to solicit perceived cases of missed and delayed diagnoses.
2007
Background: Diagnosis errors are frequent and important, but represent an underemphasized and understudied area of patient safety. Diagnosis errors are challenging to detect and dissect. It is often difficult to agree whether an error has occurred, and even harder to determine with certainty its causes and consequence. The authors applied four safety paradigms: (1) diagnosis as part of a system, (2) less reliance on human memory, (3) need to open "breathing space" to reflect and discuss, (4) multidisciplinary perspectives and collaboration. Methods: The authors reviewed literature on diagnosis errors and developed a taxonomy delineating stages in the diagnostic process: (1) access and presentation, (2) history taking/collection, (3) the physical exam, (4) testing, (5) assessment, (6) referral, and followup. The taxonomy identifies where in the diagnostic process the failures occur. The authors used this approach to analyze diagnosis errors collected over a 3-year period of weekly case conferences and by a survey of physicians. Results: The authors summarize challenges encountered from their review of diagnosis error cases, presenting lessons learned using four prototypical cases. A recurring issue is the sorting-out of relationships among errors in the diagnostic process, delay and misdiagnosis, and adverse patient outcomes. To help understand these relationships, the authors present a model that identifies four key challenges in assessing potential diagnosis error cases: (1) uncertainties about diagnosis and findings, (2) the relationship between diagnosis failure and adverse outcomes, (3) challenges in reconstructing clinician assessment of the patient and clinician actions, and (4) global assessment of improvement opportunities. Conclusions and recommendations: Finally the authors catalogue a series of ideas for change. These include: reengineering followup of abnormal test results; standardizing protocols for reading x-rays/lab tests, particularly in training programs and after hours; identifying "red flag" and "don't miss" diagnoses and situations and use of manual and automated check-lists; engaging patients on multiple levels to become "coproducers" of safer medical diagnosis practices; and weaving "safety nets" to mitigate harm from uncertainties and errors in diagnosis. These change ideas need to be tested and implemented for more timely and error-free diagnoses.
2015
Background: Missed or delayed diagnoses are a com-mon but understudied area in patient safety research. To better understand the types, causes, and prevention of such errors, we surveyed clinicians to solicit perceived cases of missed and delayed diagnoses. Methods: A 6-item written survey was administered at 20 grand rounds presentations across the United States and by mail at 2 collaborating institutions. Respondents were asked to report 3 cases of diagnostic errors and to describe their perceived causes, seriousness, and frequency. Results: A total of 669 cases were reported by 310 clini-cians from 22 institutions. After cases without diagnostic errors or lacking sufficient details were excluded, 583 re-mained. Of these, 162 errors (28%) were rated as major,
Health Affairs
Diagnostic error research has largely focused on individual clinicians' decision making and system design, while overlooking information from patients. We analyzed a unique new data source of patient-and family-reported error narratives to explore factors that contribute to diagnostic errors. From reports of adverse medical events submitted in the period January 2010-February 2016, we identified 184 unique patient narratives of diagnostic error. Problems related to patient-physician interactions emerged as major contributors. Our analysis identified 224 instances of behavioral and interpersonal factors that reflected unprofessional clinician behavior, including ignoring patients' knowledge, disrespecting patients, failing to communicate, and manipulation or deception. Patients' perspectives can lead to a more comprehensive understanding of why diagnostic errors occur and help develop strategies for mitigation. Health systems should develop and implement formal programs to collect patients' experiences with the diagnostic process and use these data to promote an organizational culture that strives to reduce harm from diagnostic error. D iagnostic errors pose a significant risk to patient safety, affecting an estimated twelve million US adult outpatients annually 1 and leading to an estimated 6-17 percent of all adverse events in hospitalized patients. 2,3 The 2015 National Academies of Science, Engineering, and Medicine report titled Improving Diagnosis in Health Care defined diagnostic error as "the failure to (a) establish an accurate and timely explanation of the patient's health problem(s) or (b) communicate that explanation to the patient." 2(p xiii) This definition signals a shift in focus that includes the patient's perspective in diagnostic error literature and highlights the fact that communication of a health issue to the patient is a fundamental part of the diagnostic process, as patients bear the most risk for harm. 2 Within the diagnostic process, patient-centered care requires strong communication; a willingness to engage patients as participants; and the ability to be responsive to patients' preferences, needs, and values. 2 Continued movement away from disease-or physician-centered care toward more patient-centric care models can foster a trusting and healing relationship between clinicians and patients. 4
Diagnosis, 2020
Background Missed vascular events, infections, and cancers account for ~75% of serious harms from diagnostic errors. Just 15 diseases from these “Big Three” categories account for nearly half of all serious misdiagnosis-related harms in malpractice claims. As part of a larger project estimating total US burden of serious misdiagnosis-related harms, we performed a focused literature review to measure diagnostic error and harm rates for these 15 conditions. Methods We searched PubMed, Google, and cited references. For errors, we selected high-quality, modern, US-based studies, if available, and best available evidence otherwise. For harms, we used literature-based estimates of the generic (disease-agnostic) rate of serious harms (morbidity/mortality) per diagnostic error and applied claims-based severity weights to construct disease-specific rates. Results were validated via expert review and comparison to prior literature that used different methods. We used Monte Carlo analysis to c...
Using voluntary reports from physicians to learn from diagnostic errors in emergency medicine
Emergency Medicine Journal, 2015
Objectives Diagnostic errors are common in the emergency department (ED), but few studies have comprehensively evaluated their types and origins. We analysed incidents reported by ED physicians to determine disease conditions, contributory factors and patient harm associated with ED-related diagnostic errors. Methods Between 1 March 2009 and 31 December 2013, ED physicians reported 509 incidents using a department-specific voluntary incident-reporting system that we implemented at two large academic hospitalaffiliated EDs. For this study, we analysed 209 incidents related to diagnosis. A quality assurance team led by an ED physician champion reviewed each incident and interviewed physicians when necessary to confirm the presence/absence of diagnostic error and to determine the contributory factors. We generated descriptive statistics quantifying disease conditions involved, contributory factors and patient harm from errors. Results Among the 209 incidents, we identified 214 diagnostic errors associated with 65 unique diseases/ conditions, including sepsis (9.6%), acute coronary syndrome (9.1%), fractures (8.6%) and vascular injuries (8.6%). Contributory factors included cognitive (n=317), system related (n=192) and non-remedial (n=106). Cognitive factors included faulty information verification (41.3%) and faulty information processing (30.6%) whereas system factors included high workload (34.4%) and inefficient ED processes (40.1%). Non-remediable factors included atypical presentation (31.3%) and the patients' inability to provide a history (31.3%). Most errors (75%) involved multiple factors. Major harm was associated with 34/209 (16.3%) of reported incidents. Conclusions Most diagnostic errors in ED appeared to relate to common disease conditions. While sustaining diagnostic error reporting programmes might be challenging, our analysis reveals the potential value of such systems in identifying targets for improving patient safety in the ED.
The incidence of diagnostic error in medicine
BMJ Quality & Safety, 2013
A wide variety of research studies suggest that breakdowns in the diagnostic process result in a staggering toll of harm and patient deaths. These include autopsy studies, case reviews, surveys of patient and physicians, voluntary reporting systems, using standardised patients, second reviews, diagnostic testing audits and closed claims reviews. Although these different approaches provide important information and unique insights regarding diagnostic errors, each has limitations and none is well suited to establishing the incidence of diagnostic error in actual practice, or the aggregate rate of error and harm. We argue 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. Three approaches appear most promising in this regard: (1) using 'trigger tools' to identify from electronic health records cases at high risk for diagnostic error; (2) using standardised patients (secret shoppers) to study the rate of error in practice; (3) encouraging both patients and physicians to voluntarily report errors they encounter, and facilitating this process.