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Analyzing diagnostic errors in the acute setting: a process-driven approach

  • Jacqueline A. Griffin ORCID logo EMAIL logo , Kevin Carr , Kerrin Bersani , Nicholas Piniella , Daniel Motta-Calderon , Maria Malik , Alison Garber , Kumiko Schnock , Ronen Rozenblum , David W. Bates , Jeffrey L. Schnipper and Anuj K. Dalal
Published/Copyright: August 23, 2021
Diagnosis
From the journal Diagnosis Volume 9 Issue 1

Abstract

Objectives

We describe an approach for analyzing failures in diagnostic processes in a small, enriched cohort of general medicine patients who expired during hospitalization and experienced medical error. Our objective was to delineate a systematic strategy for identifying frequent and significant failures in the diagnostic process to inform strategies for preventing adverse events due to diagnostic error.

Methods

Two clinicians independently reviewed detailed records of purposively sampled cases identified from established institutional case review forums and assessed the likelihood of diagnostic error using the Safer Dx instrument. Each reviewer used the modified Diagnostic Error Evaluation and Research (DEER) taxonomy, revised for acute care (41 possible failure points across six process dimensions), to characterize the frequency of failure points (FPs) and significant FPs in the diagnostic process.

Results

Of 166 cases with medical error, 16 were sampled: 13 (81.3%) had one or more diagnostic error(s), and a total of 113 FPs and 30 significant FPs were identified. A majority of significant FPs (63.3%) occurred in “Diagnostic Information and Patient Follow-up” and “Patient and Provider Encounter and Initial Assessment” process dimensions. Fourteen (87.5%) cases had a significant FP in at least one of these dimensions.

Conclusions

Failures in the diagnostic process occurred across multiple dimensions in our purposively sampled cohort. A systematic analytic approach incorporating the modified DEER taxonomy, revised for acute care, offered critical insights into key failures in the diagnostic process that could serve as potential targets for preventative interventions.

Keywords: acute care; DEER taxonomy; diagnostic error
Corresponding author: Jacqueline A. Griffin, PhD, Northeastern University, 360 Huntington Ave, 334 Snell Engineering, Boston, MA, USA, E-mail:

Funding source: Agency for Healthcare Research and Quality

Award Identifier / Grant number: R18HS026613

Acknowledgments

We would like to thank Drs. Marc Pimentel and Mallika Mendu and Dr. Nina Chalfin for providing cases from the Brigham and Women’s Hospital (BWH) Morbidity and Mortality review process, and Brigham Health’s Hospital Medicine Unit Quality Assurance committee, respectively.

  1. Research funding: This research is funded by AHRQ PSLL Award R18 - HS026613.

  2. Author contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission.

  3. Competing interests: Dr. Dalal reports consulting fees from MayaMD, which makes AI software for patient engagement and decision support. Dr. Rozenblum reports having an equity in Hospitech Respiration Ltd, which makes Airway Management Solutions. Dr. Bates reports grants and personal fees from EarlySense, personal fees from CDI Negev, equity from ValeraHealth, equity from Clew, equity from MDClone, personal fees and equity from AESOP, and grants from IBM Watson Health, outside the submitted work. Authors otherwise report no conflicts of interest.

  4. Informed consent: Not applicable.

  5. Ethical approval: The local Institutional Review Board provided approval for the conduct of this study.

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Supplementary Material

The online version of this article offers supplementary material (https://doi.org/10.1515/dx-2021-0033).

Received: 2021-03-09
Accepted: 2021-07-26
Published Online: 2021-08-23

© 2021 Walter de Gruyter GmbH, Berlin/Boston

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https://doi.org/10.1515/dx-2021-0033
Keywords for this article
acute care; DEER taxonomy; diagnostic error

Articles in the same Issue

  1. Frontmatter
  2. Editorial
  3. From Camille Nούς to Apollonian and the Dionysian scientists
  4. Review
  5. The role of D-dimer in periprosthetic joint infection: a systematic review and meta-analysis
  6. Mini Reviews
  7. Updated picture of SARS-CoV-2 variants and mutations
  8. Systematic review and cumulative meta-analysis of the diagnostic accuracy of glial fibrillary acidic protein vs. S100 calcium binding protein B as blood biomarkers in observational studies of patients with mild or moderate acute traumatic brain injury
  9. Opinion Papers
  10. The 6C model for accurately capturing the patient’s medical history
  11. Webside manner: maskless communication
  12. Original Articles
  13. Ways that nurse practitioner students self-explain during diagnostic reasoning
  14. Diagnostic reasoning: relationships among expertise, accuracy, and ways that nurse practitioner students self-explain
  15. Perspectives on the current state of pre-clerkship clinical reasoning instruction in United States medical schools: a survey of clinical skills course directors
  16. Use of a structured approach and virtual simulation practice to improve diagnostic reasoning
  17. Analyzing diagnostic errors in the acute setting: a process-driven approach
  18. Morning report goes virtual: learner experiences in a virtual, case-based diagnostic reasoning conference
  19. Stroke hospitalization after misdiagnosis of “benign dizziness” is lower in specialty care than general practice: a population-based cohort analysis of missed stroke using SPADE methods
  20. Discrepancy between emergency department admission diagnosis and hospital discharge diagnosis and its impact on length of stay, up-triage to the intensive care unit, and mortality
  21. Automated capture-based NGS workflow: one thousand patients experience in a clinical routine framework
  22. Short Communication
  23. Characterizing the relationship between diagnostic intensity and quality of care
  24. Case Reports – Lessons in Clinical Reasoning
  25. Lessons in clinical reasoning ‒ pitfalls, myths, and pearls: a case of confusion, disequilibrium, and “picking at the air”
  26. Hickam’s dictum, Occam’s razor, and Crabtree’s bludgeon: a case of renal failure and a clavicular mass
  27. Letters to the Editor
  28. Three learning concepts to improve diagnosis and enhance the practice of medicine
  29. Distributed cognition: a framework for conceptualizing telediagnosis in teams
  30. Performance of Fujirebio Espline SARS-CoV-2 rapid antigen test for identifying potentially infectious individuals
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