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: Medical misadventure, defined as unintended harm caused during medical care or procedures, is an increasingly significant concern in patient safety and healthcare quality. Recent decades have seen heightened awareness and reporting of such incidents globally, including in the United States. This study quantifies trends in medical misadventure-related mortality and morbidity by examining regional disparities [...]

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: Accurate, timely admission medication reconciliation (AMR) is a key patient-safety driver. Clinician-performed AMR has higher error rates compared to pharmacy-performed AMR. At our large, tertiary care institution, pharmacists capture only 75% of AMRs and require up to 48h for completion. Delays and errors in clinician-performed AMR on medicine floors have led to patient safety [...]

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: Medical errors are the third leading cause of death in the United States yet physicians report minimal education on how to disclose errors and adverse events. To Err is Human shed light on the severity of errors. As a result, communication and resolution programs were developed over the past two decades to attempt to [...]

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 [...]