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 […]

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 […]

Background: Error reporting is an integral component in the safety program of hospitals. Residents in training programs are encouraged and expected to participate in error reporting as part of the clinical learning environment. Previous studies identified barriers to resident reporting including knowledge of how to submit reports and understanding how reports affect institutional safety culture. […]

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 […]

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 […]

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 […]

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 […]

Case Presentation: An 82-year-old woman with hypertension, diabetes, and a renal transplant recipient for diabetic nephropathy was admitted with three days of chills, cough, dyspnea, and increased urinary frequency. Her urinalysis was positive for pyuria and hematuria, and she was diagnosed with cystitis. Chest radiograph on admission was read as clear by radiology. She was […]

Background: Communication related to medications is an important metric on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey to measure patient experience after discharge from the hospital. There are many factors which can lead to poor communication about medications (Figure 1). Over 20% of readmissions can be related to medications, and of […]

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 […]