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Search2020-05-20T12:01:36-05:00
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Search Results for Diagnostic Error
Plenary Presentations
Abstract Number: PL3
DIAGNOSTIC ERRORS IN PATIENTS WHO DIED OR WERE TRANSFERRED TO AN ICU: PRELIMINARY RESULTS FROM THE UPSIDE STUDY
SHM Converge 2022
Background: Diagnostic errors (DE), defined as missed opportunities to make a correct or timely diagnosis based on the available evidence, are a critical but understudied cause of patient harm. While previous efforts have focused on examining the incidence and factors contributing to DEs in ambulatory and emergency room settings, fewer studies have examined incidence of […]
Abstract Number: A2
DIAGNOSTIC PROCESS FAILURE POINTS ASSOCIATED WITH DIAGNOSTIC FAILURE IN THE HOSPITAL
SHM Converge 2022
Background: Diagnostic errors (DE) often occur in the hospital and can lead to preventable harm. As part of our AHRQ-funded Patient Safety Learning Laboratory, we previously estimated the prevalence of DE to be 22.7% in a stratified cohort of patients hospitalized on the general medicine service. Using a structured electronic health record (EHR) chart review […]
Abstract Number: M2
MISSED IN THE SHIFT — DELAY IN MAKING AN IMPERATIVE DIAGNOSIS AMIDST CARE TRANSITIONS
SHM Converge 2022
Case Presentation: A 44-year-old man with multiple myeloma and cardiac amyloidosis on chemotherapy, and atrial fibrillation on apixaban, presented with three days of worsening shortness of breath and edema. He was admitted to the emergency room observation unit for treatment of a mild heart failure exacerbation. He was noted on admission to have rapidly developed […]
Abstract Number: A11
OVERDIAGNOSIS OF COMMUNITY-ACQUIRED PNEUMONIA: RISK FACTORS AND OUTCOMES FROM A 48 HOSPITAL COHORT STUDY
SHM Converge 2022
Background: Community-acquired pneumonia (CAP) is the most common infectious diagnosis necessitating adult hospitalization in the United States (US). Timely diagnosis of CAP is important to improve patient outcomes. However, overdiagnosis of CAP, or treatment of CAP despite inadequate signs or symptoms of CAP, may also pose a significant threat to patient safety. Potential harm of […]
Abstract Number: E44
DEATH IN A PATIENT WITH HUMAN DEFICIENCY VIRUS DUE TO A TICKING TIME BOMB
SHM Converge 2022
Case Presentation: A 53 year old male Missouri resident with a prior history of intravenous drug use, traumatic subdural hematoma, seizure disorder and a diagnosis of human immunodeficiency virus (HIV) / acquired immunodeficiency syndrome (AIDS) in 1990 presented to his local hospital in April with a 1 day history of fever and confusion. He was […]
Abstract Number: F33
DELAYED PNEUMOCYSTIS PNEUMONIA DIAGNOSIS- ANALYZING DIAGNOSTIC ERRORS
SHM Converge 2022
Case Presentation: 71-year-old female with history of DM2, HTN, breast carcinoma in situ status post mastectomy, B-cell lymphoma (R-CHOP in 2016 & RT, currently in remission), autoimmune hepatitis related cirrhosis on Azathioprine presented to the hospital with a 4-day history of progressively worsening productive cough, mild hemoptysis, fever and shortness of breath. In the Emergency […]
Abstract Number: G27
DIAGNOSTIC ERROR IN A PATIENT WITH LIFE-THREATENING ANEMIA AND SEVERE GASTROINTESTINAL HEMORRHAGE
SHM Converge 2022
Case Presentation: A 76 year-old woman with coronary artery disease, hypertension, and chronic kidney disease presented to the ER with a one-day history of profound generalized weakness and acute severe anemia. She had known diverticulosis and was taking aspirin 81 mg twice daily status-post a left total hip arthroplasty three weeks prior. Review of systems […]
Abstract Number: G28
DON’T STOP THE DIAGNOSTIC PROCESS, BECAUSE ‘WINNERS DON’T QUIT AND QUITTERS DON’T WIN’
SHM Converge 2022
Case Presentation: A 90-year-old-male with history of hypertension, coronary artery disease and chronic lymphocytic lymphoma presented with shortness of breath that had been getting worse over the previous few weeks, particularly at night and with lying down. He also reported increased cough and worsening leg swelling. In the ED, he was hypoxic (84% on room […]
Abstract Number: G43
SHUNTED TO PSYCHIATRY: DELAYED DIAGNOSIS OF HEREDITARY HEMORRHAGIC TELANGIECTASIA
SHM Converge 2022
Case Presentation: A 29-year-old man with a history of mood disorder was admitted with acute encephalopathy after friends had requested a welfare check. The patient was found to have nonsensical speech, delusions of alien interaction and possible gait ataxia without other signs of focal neurological deficits. Vitals were within normal limits; no other significant physical […]
Abstract Number: J11
PREVALENCE AND CAUSES OF DIAGNOSTIC ERRORS IN PATIENTS HOSPITALIZED UNDER INVESTIGATION FOR COVID-19 INFECTION
SHM Converge 2022
Background: The COVID-19 pandemic required physicians to care for a new disease with uncertain and evolving characteristics while also adhering to physical and social distancing practices, and under conditions of extreme duress – all factors likely to lead to missed or delayed diagnoses among patients admitted ‘under investigation’ for COVID-19. Methods: We carried out a […]
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  • A Patient’s Presentation of Persistent Sweet Taste in Her Mouth Leads to a Diagnosis of Small Cell Lung Cancer
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