Background: Diagnostic errors have been cited as a potential contributor to hospital readmissions, particularly early readmissions (e.g. within 7 days), but little is known about their frequency and characteristics. We performed structured chart review of all medical patients readmitted within 7 days of discharge from a single academic medical center to describe the prevalence of [...]

Background: Diagnostic errors have been cited as a potential contributor to hospital readmissions, particularly early readmissions (e.g. within 7 days), but little is known about their frequency and characteristics. We performed structured chart review of all medical patients readmitted within 7 days of discharge from a single academic medical center to describe the prevalence of [...]

Background: Diagnostic error in acute care represents an unresolved safety issue: error rates range from 4.8 to 49.8%. If the diagnosis is delayed or incorrect, the patient may not get correct treatment in a timely manner. Underlying contributing factors include system flaws (e.g., communication barriers) and cognitive errors (e.g., anchoring), factors that are often overlooked [...]

Background: Diagnostic errors have been cited as a potential contributor to hospital readmissions, particularly early readmissions (e.g. within 7 days). A single prior study of early readmissions applied a binary (yes/no) metric to assess for diagnostic error in early readmissions, but this may be an insensitive method. Past studies of diagnostic error in primary care [...]

Background: High quality clinical documentation is essential for patient safety. Thoughtful clinical documentation transmits one’s clinical reasoning and is considered to be a professional responsibility. There are no accepted standards for assessing documentation with respect to clinical reasoning. We therefore undertook this study to establish a metric to evaluate hospitalists’ documentation of clinical reasoning in [...]

Background: Increasing attention has been paid to diagnostic patient safety vulnerabilities, which account for 6 to 17% of hospital adverse events. In 2015, the National Academies of Medicine published a report on diagnostic safety errors, including their causes and evidence to-date on how to intervene to reduce the harm associated with them. In this report, [...]

Case Presentation: A 83-year-old woman of Chinese origin with remote history of breast cancer and pulmonary fibrosis of unknown etiology presented to care with one month of fevers, night sweats, malaise, and cough. After three negative acid-fast bacillus (AFB) smears and CT chest showing chronic right apical scarring during hospital admission, she was discharged on [...]