Session Type
Meeting
Search Results for Diagnostic Error
Abstract Number: M2
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: 128
SHM Converge 2021
Background: Diagnostic errors (DE) – defined as incorrect, missed, or delayed diagnoses not made within a timeframe consistent with standard clinical practice – are common and can lead to harm, especially in acute care settings. One cause of DEs is suboptimal clinical reasoning in the diagnostic process. Electronic clinical documentation has been suggested to potentially […]
Abstract Number: 129
SHM Converge 2021
Background: To date, attempts at estimating diagnostic error (DE), as defined as missed, incorrect, or delayed diagnoses, have focused on the identification of all types of adverse events, not specifically DE. Retrospectively identifying and ascertaining DE for hospitalized patients has been further challenged by (1) variability in operational definitions of DE; (2) use of non-standardized […]
Abstract Number: 137
Hospital Medicine 2016, March 6-9, San Diego, Calif.
Background: Transitions of care, whether between or within institutions, are an important source of errors, inefficiency, and unnecessary costs. Inter-hospital transfers are complicated by incongruent information systems, indirect and asynchronous communication, and geographical distance all in settings of high patient complexity and acuity. We developed a large database of patients transferred between hospitals to identify […]
Abstract Number: 162
Hospital Medicine 2018; April 8-11; Orlando, Fla.
Background: Diagnostic error in medicine is increasingly recognized as “the next frontier for patient safety”. Current research has explored the etiologies of diagnostic errors in two unique dimensions: as systems-based or cognitive-based causes. One study, however, suggests that roughly half of all errors stem from both domains. Using a focused ethnographic approach, we sought to […]
Abstract Number: 168
SHM Converge 2023
Background: Diagnostic and clinical reasoning errors are common and a source of harm to our patients. Improving clinical reasoning skills is challenging due to the absence of feedback. Care transitions have been recognized as an area of vulnerability for hospitalized patients, however, they also represent opportunities for error recognition and improvement as the oncoming clinician […]
Abstract Number: 171
SHM Converge 2023
Background: Diagnostic errors (DEs) are common and can lead to preventable harm in hospitalized patients.[1] To address this problem as part of our AHRQ-funded Patient Safety Learning Laboratory, we characterized diagnostic process failures that contribute to DEs.[2,3] Next, we refined three interventions (Figure 1) that addressed common process failures and were embedded into our electronic […]
Abstract Number: 173
Hospital Medicine 2020, Virtual Competition
Background: Diagnostic error is commonly defined as a missed or delayed diagnosis and has been described as among the most important patient safety hazards. Diagnostic errors also account for the largest category of medical malpractice high severity claims and total payouts. Despite a large literature on the incidence of inpatient adverse events, no systematic review […]
Abstract Number: 178
Hospital Medicine 2020, Virtual Competition
Background: Diagnostic errors in hospitalized patients are difficult to identify and quantify: error rates range from 4.8 to 49.8%. Though chart review tools, like the Safer Dx instrument, have been developed to assess the presence of diagnostic error in ambulatory settings, they have yet to be validated for acute care. A key issue is identifying […]
Abstract Number: 187
Hospital Medicine 2020, Virtual Competition
Background: Clinicians often diagnose bacterial infections such as urinary tract infection (UTI) and pneumonia in patients who are asymptomatic or have non-bacterial causes of their symptoms. Misdiagnosis of infection leads to unnecessary antibiotic use and potentially delays correct diagnoses. Interventions to improve diagnosis often focus on infections separately. However, if misdiagnosis is linked at the […]