Diagnostic error in the emergency department: learning from national patient safety incident report analysis

Abstract

BackgroundDiagnostic error occurs more frequently in the emergency department than in regular in-patient hospital care. We sought to characterise the nature of reported diagnostic error in hospital emergency departments in England and Wales from 2013 to 2015 and to identify the priority areas for intervention to reduce their occurrence.MethodsA cross-sectional mixed-methods design using an exploratory descriptive analysis and thematic analysis of patient safety incident reports. Primary data were extracted from a national database of patient safety incidents. Reports were filtered for emergency department settings, diagnostic error (as classified by the reporter), from 2013 to 2015. These were analysed for the chain of events, contributory factors and harm outcomes.ResultsThere were 2288 cases of confirmed diagnostic error: 1973 (86%) delayed and 315 (14%) wrong diagnoses. One in seven incidents were reported to have severe harm or death. Fractures were the most common condition (44%), with cervical-spine and neck of femur the most frequent types. Other common conditions included myocardial infarctions (7%) and intracranial bleeds (6%). Incidents involving both delayed and wrong diagnoses were associated with insufficient assessment, misinterpretation of diagnostic investigations and failure to order investigations. Contributory factors were predominantly human factors, including staff mistakes, healthcare professionals’ inadequate skillset or knowledge and not following protocols.ConclusionsSystems modifications are needed that provide clinicians with better support in performing patient assessment and investigation interpretation. Interventions to reduce diagnostic error need to be evaluated in the emergency department setting, and could include standardised checklists, structured reporting and technological investigation improvements.

Validation of chief complaints, medical history, medications, and physician diagnoses structured with an integrated emergency department information system in Japan: the Next Stage ER system

“…Additionally, physicians’ diagnoses should reflect patients’ conditions more accurately compared to conditions indicated by claims codes. As one of the ED principles is to reduce the risk of misdiagnosis for patient safety, knowing the physicians’ diagnoses made in the ED is especially important for providing relevant feedback and retrospective assessment 28 . Although the current findings suggest that the structured data with the NSER system have high accuracy, except for certain conditions, the accuracy could be, at least partially, improved by the use of combined procedure and/or prescription codes if available.…”

Diagnostic error in hospitals: finding forests not just the big trees

“…5-7 18 21 27 This suggests that an exclusive focus on the 'Big Three' would neglect a substantial proportion of other common and harmful diagnostic errors. 27 Furthermore, research on contributing factors of diagnostic errors reveals a number of common system and process factors that would require robust diseaseagnostic approaches. If funding and advocacy for diagnostic safety becomes mostly disease oriented, it will pull resources away from broader 'disease-agnostic' research and quality improvement efforts needed to understand and address these underlying system and process factors.…”

Adolescent Haematocolpos: Seek and You Shall Find

“…[4] Unnecessary delays can arise in other cases due to inadequate skills, hesitancy to take complete histories or conduct appropriate physical examinations or poor communications among staff. [5][6][7] This case of adolescent haematocolpos, discussed herein, illustrates how these considerations can result in very substantial delays in accurately diagnosing and treating a patient.…”