Background: Diagnostic errors (DEs), or the failure to accurately identify or provide timely explanations of a patient’s health problem, are a significant source of patient harm. DEs occur in up to 23% of adult inpatients who transfer to intensive care units (ICU) or die. Few studies have examined how clinician team composition impacts DE risk. [...]

Background: Diagnostic errors (DEs), or the failure to accurately identify or provide timely explanations of a patient’s health problem, are a significant source of patient harm. DEs occur in up to 23% of adult inpatients who transfer to intensive care units (ICU) or die. Few studies have examined how clinician team composition impacts DE risk. [...]

Background: Diagnostic errors (DE) are common in patients who die or go to the ICU and are caused by gaps in diagnostic processes. Few data describe whether this observation holds true among patients with sepsis, a disease that progresses quickly and requires a range of clinical information to diagnose correctly. The objective of our study [...]

Background: Diagnostic error may occur in up to 5% of all adult hospitalizations, leading to prolonged length of stay, higher cost, and significant morbidity and mortality. Improving diagnostic safety requires measurement, analysis, and learning accelerated by dissemination. While safety is at the forefront of hospital priorities, organizational readiness to address diagnostic safety lacks consistent deployment [...]

Background: Diagnostic errors frequently represent significant adverse events that can occur in any medical setting, particularly in rushed handovers and constrained timing. Cases that result in emergency hospitalization at the time of the initial outpatient visit are more likely to have complex or serious patient conditions and more detrimental diagnostic errors. Our study investigated diagnostic [...]

Background: Diagnostic error is a major threat to the safety of hospitalized patients, affecting as many as 1 in 4 patients and leading to 7% of inpatient deaths. However, diagnostic error remains difficult to identify and measure, particularly in the hospital setting, where determination of an error relies on medical record review. Measurement difficulty also [...]

Background: Diagnostic errors (DE) are common in hospitalized patients, especially those with an unintended escalation of care, and cause substantial harm. However, individual hospitals currently lack methods to analyze local diagnostic process failure patterns to identify targets for quality improvement efforts. Purpose: The AHRQ funded UPSIDE study identified key diagnostic process failures across a national [...]

Case Presentation: A 63-year-old woman with end-stage renal disease on dialysis and bilateral lung transplant was admitted from a rehab facility with generalized weakness and anemia in the setting of missed dialysis. At presentation, she had fluid-responsive hypotension, borderline fever, and a normal heart rate. She had no localizing infectious signs or symptoms. An infectious [...]

Case Presentation: A 92 year old female with a PMH significant for occipital neuralgia, glaucoma, cataracts, HTN, HLD, chronic lower extremity edema, and GERD presented to the ED with complaints of headache, cough, congestion, and RUQ pain. She had no history of tobacco or drug use. Her medications included Gabapentin, Tylenol, Tramadol, Losartan, Simvastatin, Lasix, [...]

Case Presentation: 49 year old woman with past medical history of alcoholic cirrhosis and autoimmune hemolytic anemia treated with a course of steroids and rituximab 3 months prior who presented with 3-days of nausea, nonbloody/nonbilious vomiting and diarrhea associated with dysuria, and suprapubic discomfort. Vitals notable for heart rate 129/min, BP 115/61mmHg. Labs significant for [...]