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Open Access 01-12-2019 | Research article

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

Authors: Faris Hussain, Alison Cooper, Andrew Carson-Stevens, Liam Donaldson, Peter Hibbert, Thomas Hughes, Adrian Edwards

Published in: BMC Emergency Medicine | Issue 1/2019

Abstract

Background

Diagnostic 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.

Methods

A 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.

Results

There 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.

Conclusions

Systems 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.

Berner ES, Graber ML. Overconfidence as a cause of diagnostic error in medicine. Am J Med. 2008;121(5 Suppl):S2–23. https://doi.org/10.1016/j.amjmed.2008.01.001.CrossRefPubMed

Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG, et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. New Engl J Med. 1991;324(6):370–6. https://doi.org/10.1056/NEJM199102073240604.CrossRefPubMed

The College of Emergency Medicine Acute and Emergency Care: prescribing the remedy. 2014 The College of Emergency Medicine; 2017.

Society to Improve Diagnosis in Medicine. About diagnostic error. The Institute of Medicine Website: Society to Improve Diagnosis in Medicine; 2017 (Accessed 13/10/2017). Available from: http://www.improvediagnosis.org/page/AboutDiagnosticErr

Anandaciva S. A&E performance reaches new low. London: The King's Fund; 2018 (Accessed 20/04/2018). Available from: https://http://www.kingsfund.org.uk/blog/2018/01/ae-performance-reaches-new-low.

Royal College of Physicians. Hospitals on the Edge? The time for action. A report by the Royal College of Physicians. London: Royal College of Physicians; 2012.

Blunt I. Focus on preventable admissions: research report. London. 2013.

Pope I, Burn H, Ismail SA, Harris T, McCoy D. A qualitative study exploring the factors influencing admission to hospital from the emergency department. BMJ Open. 2017;7(8).CrossRef

NHS England. Quarterly Hospital Activity. https://http://www.england.nhs.uk/statistics/statistical-work-areas/hospital-activity/quarterly-hospital-activity/; 2017.

10.

The King's Fund. What's going on in A&E? The key questions answered. https://http://www.kingsfund.org.uk/projects/urgent-emergency-care/urgent-and-emergency-care-mythbusters - number-of-people-going-to-ae; 2017.

11.

Cassam Q. Diagnostic Error, Overconfidence and Self-Knowledge Palgrave Communications 2017;3.

12.

Singh H, Giardina T, Meyer AD, Forjuoh SN, Reis MD, Thomas EJ. Types and origins of diagnostic errors in primary care settings. JAMA Intern Med. 2013;173(6):418–25. https://doi.org/10.1001/jamainternmed.2013.2777.CrossRefPubMedPubMedCentral

13.

Newman-Toker DE, Makary MA. Measuring diagnostic errors in primary care: the first step on a path forward comment on “types and origins of diagnostic errors in primary care settings”. JAMA Intern Med. 2013;173(6):425–6. https://doi.org/10.1001/jamainternmed.2013.225.CrossRefPubMed

14.

Graber ML. The incidence of diagnostic error in medicine. BMJ Qual Saf. 2013.

15.

Guly HR. Diagnostic errors in an accident and emergency department. Emerg Med J : EMJ. 2001;18(4):263–9.CrossRef

16.

Warrick C, Patel P, Hyer W, Neale G, Sevdalis N, Inwald D. Diagnostic error in children presenting with acute medical illness to a community hospital. Int J Qual Health Care. 2014;26(5):538–46. https://doi.org/10.1093/intqhc/mzu066.CrossRefPubMed

17.

Kachalia A, Gandhi TK, Puopolo AL, Yoon C, Thomas EJ, Griffey R, et al. Missed and delayed diagnoses in the emergency department: a study of closed malpractice claims from 4 liability insurers. Ann Emerg Med. 2007;49(2):196–205. https://doi.org/10.1016/j.annemergmed.2006.06.035.CrossRefPubMed

18.

Chellis M, Olson J, Augustine J, Hamilton G. Evaluation of missed diagnoses for patients admitted from the emergency department. Acad Emerg Med Off J Soc Acad Emerg Med. 2001;8(2):125–30.CrossRef

19.

Sevdalis N, Jacklin R, Arora S, Vincent CA, Thomson RG. Diagnostic error in a national incident reporting system in the UK. J Eval Clin Pract. 2010;16(6):1276–81. https://doi.org/10.1111/j.1365-2753.2009.01328.x.CrossRefPubMed

20.

Tighe CM, Woloshynowych M, Brown R, Wears B, Vincent C. Incident reporting in one UK accident and emergency department. Accid Emerg Nurs. 2006;14(1):27–37. https://doi.org/10.1016/j.aaen.2005.10.001.CrossRefPubMed

21.

Hocagil H, Karakilic E, Hocagil C, Senlikci H, Buyukcam F. Underdiagnosis of anaphylaxis in the emergency department: misdiagnosed or miscoded? Hong Kong medical journal = Xianggang yi xue za zhi. 2013;19(5):429–33. https://doi.org/10.12809/hkmj133895.CrossRefPubMed

22.

Kurabayashi M, Miwa N, Ueshima D, Sugiyama K, Yoshimura K, Shimura T, et al. Factors leading to failure to diagnose acute aortic dissection in the emergency room. J Cardiol. 2011;58(3):287–93. https://doi.org/10.1016/j.jjcc.2011.07.008.CrossRefPubMed

23.

Okafor N, Payne VL, Chathampally Y, Miller S, Doshi P, Singh H. Using voluntary reports from physicians to learn from diagnostic errors in emergency medicine. Emerg Med J : EMJ. 2016;33(4):245–52. https://doi.org/10.1136/emermed-2014-204604.CrossRefPubMed

24.

Medford-Davis L, Park E, Shlamovitz G, Suliburk J, Meyern AND, Singh H. Diagnostic errors related to acute abdominal pain in the emergency department. Emerg Med J : EMJ. 2016;33(4):253–9. https://doi.org/10.1136/emermed-2015-204754.CrossRefPubMed

25.

Wet Cd. An overview of patient safety in primary care NHS Scotland website: Scotland N; 2012. Available from: http://www.nes.scot.nhs.uk/media/2075343/an-overview-of-patient-safety-in-primary-care-nov-12.pdf.

26.

Schiff GD, Hasan O, Kim S, et al. Diagnostic error in medicine: analysis of 583 physician-reported errors. Arch Intern Med. 2009;169(20):1881–7. https://doi.org/10.1001/archinternmed.2009.333.CrossRefPubMed

27.

Vincent CA. Analysis of clinical incidents: a window on the system not a search for root causes. Qual Saf Health Care. 2004;13(4):242.CrossRef

28.

Donaldson LJ, Panesar SS, Darzi A. Patient-safety-related hospital deaths in England: thematic analysis of incidents reported to a national database, 2010–2012. PLoS Med. 2014;11(6):e1001667. https://doi.org/10.1371/journal.pmed.1001667.CrossRefPubMedPubMedCentral

29.

Rees P, Edwards A, Powell C, Hibbert P, Williams H, Makeham M, et al. Patient Safety Incidents Involving Sick Children in Primary Care in England and Wales: A Mixed Methods Analysis. PLoS Med. 2017;14(1):e1002217. https://doi.org/10.1371/journal.pmed.1002217.CrossRefPubMedPubMedCentral

30.

Cooper A, Edwards A, Williams H, Evans HP, Avery A, Hibbert P, et al. Sources of unsafe primary care for older adults: a mixed-methods analysis of patient safety incident reports. Age Ageing. 2017;46(5):833–9. https://doi.org/10.1093/ageing/afx044.CrossRefPubMedPubMedCentral

31.

NHS. Patient Safety-Report a Patient Safety Incident. http://www.nrls.nhs.uk/report-a-patient-safety-incident/: NHS; 2017 [accessed 13/10/2017]. Available from: http://www.nrls.nhs.uk/report-a-patient-safety-incident/

32.

Care Quality Commission. Notifications required by the Health and Social Care Act 2008: Guidance for English NHS providers. London: Care Quality Commission; 2013.

33.

Carson-Stevens A, Hibbert P, Avery A, Butlin A, Carter B, Cooper A, et al. A cross-sectional mixed methods study protocol to generate learning from patient safety incidents reported from general practice. BMJ Open. 2015;5(12):e009079. https://doi.org/10.1136/bmjopen-2015-009079.CrossRefPubMedPubMedCentral

34.

Cooper J, Edwards A, Williams H, Sheikh A, Parry G, Hibbert P, et al. Nature of blame in patient safety incident reports: mixed methods analysis of a National Database. Ann Fam Med. 2017;15(5):455–61. https://doi.org/10.1370/afm.2123.CrossRefPubMedPubMedCentral

35.

Fletcher M, Castro G, Hatlie M, Hibbert P, Jakob R, Koss R. Conceptual Framework for the International Classification for Patient Safety. WHO website: WHO; 2009. Available from: http://www.who.int/patientsafety/taxonomy/icps_full_report.pdf

36.

Makeham MAB, Stromer S, Bridges-Webb C, Mira M, Saltman DC, Cooper C, et al. Patient safety events reported in general practice: a taxonomy. Qual Saf Health Care. 2008;17(1):53.CrossRef

37.

Clarke V, Braun V. Thematic analysis. In: Teo T, editor. Encyclopedia of critical psychology. New York, NY: Springer New York; 2014. p. 1947–52.CrossRef

38.

Vaismoradi M, Turunen H, Bondas T. Content analysis and thematic analysis: implications for conducting a qualitative descriptive study. Nurs Health Sci. 2013;15(3):398–405. https://doi.org/10.1111/nhs.12048.CrossRefPubMed

39.

Goldman D. How do you use a driver diagram? Institute of Healthcare Improvement; 2017 (Accessed 16/10/2017). Available from: http://www.ihi.org/education/ihiopenschool/resources/Pages/Activities/GoldmannDriver.aspx.

40.

Sari AB-A, Sheldon TA, Cracknell A, Turnbull A. Sensitivity of routine system for reporting patient safety incidents in an NHS hospital: retrospective patient case note review. BMJ : British Med J. 2007;334(7584):79. https://doi.org/10.1136/bmj.39031.507153.AE.CrossRef

41.

Haller H, Cramer H, Lauche R, Dobos G. Somatoform disorders and medically unexplained symptoms in primary care. Deutsches Arzteblatt Int. 2015;112(16):279–87. https://doi.org/10.3238/arztebl.2015.0279.CrossRef

42.

Alsma J, van de Wouw J, Jellema K, Coffeng S, Tobback E, Delesie L, et al. Medically unexplained physical symptoms in patients visiting the emergency department : an international multicentre retrospective study. Eur J Med. 2018.

43.

NHS Improvement. NRLS official statistics publications: data quality statement. London: NHS Improvement; 2018.

44.

NHS Improvement. The future of the patient safety incident reporting: upgrading the NRLS. London: NHS Improvement; 2017.

45.

Vincent C, Stanhope N, Crowley-Murphy M. Reasons for not reporting adverse incidents: an empirical study. J Eval Clin Pract. 1999;5(1):13–21. https://doi.org/10.1046/j.1365-2753.1999.00147.x.CrossRefPubMed

46.

Rees P, Edwards A, Powell C, Evans HP, Carter B, Hibbert P, et al. Pediatric immunization-related safety incidents in primary care: A mixed methods analysis of a national database. Vaccine. 2015;33(32):3873–80. https://doi.org/10.1016/j.vaccine.2015.06.068.CrossRefPubMedPubMedCentral

47.

Graber M, Gordon R, Franklin N. Reducing Diagnostic Errors in Medicine: What's the Goal? Acad Med. 2002;77(10).CrossRef

48.

Norman G. Building on experience — the development of clinical reasoning. N Engl J Med. 2006;355(21):2251–2. https://doi.org/10.1056/NEJMe068134.CrossRefPubMed

49.

Kovacs G, Croskerry P. Clinical decision making: an emergency medicine perspective. Acad Emerg Med. 1999;6(9):947–52. https://doi.org/10.1111/j.1553-2712.1999.tb01246.x.CrossRefPubMed

50.

Ely JW, Graber ML, Croskerry P. Checklists to Reduce Diagnostic Errors. Acad Med. 2011;86(3).CrossRef

51.

Graber ML, Kissam S, Payne VL, Meyer AND, Sorensen A, Lenfestey N, et al. Cognitive interventions to reduce diagnostic error: a narrative review. BMJ Qual Saf. 2012;21(7):535.CrossRef

52.

Espinosa JA, Nolan TW. Reducing errors made by emergency physicians in interpreting radiographs: longitudinal study. BMJ. 2000;320(7237):737.CrossRef

53.

Howard J, Sundararajan R, Thomas SG, Walsh M, Sundararajan M. Reducing Missed Injuries at a Level II Trauma Center. J Trauma Nurs. 2006;13(3).CrossRef

54.

White T, Woodmansey P, Ferguson DG, Channer KS. Improving the interpretation of electrocardiographs in an accident and emergency department. Postgrad Med J. 1995;71(833):132.CrossRef

55.

Shapiro MJ, Morey JC, Small SD, Langford V, Kaylor CJ, Jagminas L, et al. Simulation based teamwork training for emergency department staff: does it improve clinical team performance when added to an existing didactic teamwork curriculum? Qual Saf Health Care. 2004;13(6):417.CrossRef

56.

McLauchlan CA, Jones K, Guly HR. Interpretation of trauma radiographs by junior doctors in accident and emergency departments: a cause for concern? J Accid Emerg Med. 1997;14(5):295.CrossRef

57.

Brady AP. Error and discrepancy in radiology: inevitable or avoidable? Insights Imaging. 2017;8(1):171–82. https://doi.org/10.1007/s13244-016-0534-1.CrossRefPubMed

58.

Pinto A, Berritto D, Russo A, Riccitiello F, Caruso M, Belfiore M, et al. Traumatic fractures in adults: missed diagnosis on plain radiographs in the Emergency Department. Acta Biomed. 2018;89(Supplement 1):111–23.PubMedPubMedCentral

59.

Marcovici PA, Taylor GA. Structured radiology reports are more complete and more effective than unstructured reports. AJR. 2014;203:1265.CrossRef

60.

Yates T. The antidote for radiology errors. Imaging technology news website; 2012 (Accessed 20/2/2018). Available from: https://http://www.itnonline.com/article/antidote-radiology-errors.

61.

Waite S, Scott J, Gale B, Fuchs T, Kolla S, Reede D. Interpretive error in radiology. Am J Roentgenol. 2016;208(4):739–49. https://doi.org/10.2214/AJR.16.16963.CrossRef

62.

Van Zyl HP, Bilbey J, Vukusic A, Ring T, Oakes J, Williamson LD, et al. Can emergency physicians accurately rule out clinically important cervical spine injuries by using computed tomography? Can J Emerg Med. 2014;16(2):131–5. https://doi.org/10.2310/8000.2013.130978.CrossRef

63.

Lee CS, Nagy PG, Weaver SJ, Newman-Toker DE. Cognitive and system factors contributing to diagnostic errors in radiology. AJR. 2013;201:611.CrossRef

64.

Bruno MA, Walker EA, Abujudeh HH. Understanding and confronting our mistakes: the epidemiology of error in radiology and strategies for error reduction. RadioGraphics. 2015;35(6):1668–76. https://doi.org/10.1148/rg.2015150023.CrossRefPubMed

65.

Rubin GD. Lung nodule and Cancer detection in CT screening. J Thorac Imaging. 2015;30(2):130–8. https://doi.org/10.1097/RTI.0000000000000140.CrossRefPubMedPubMedCentral

66.

Miyakis S, Karamanof G, Liontos M, Mountokalakis TD. Factors contributing to inappropriate ordering of tests in an academic medical department and the effect of an educational feedback strategy. Postgrad Med J. 2006;82(974):823.CrossRef

67.

Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA. 2007;297(8):831–41. https://doi.org/10.1001/jama.297.8.831.CrossRefPubMed

68.

Metcalfe D, Sugand K, Thrumurthy SG, Thompson MM, Holt PJ, Karthikesalingam AP. Diagnosis of ruptured abdominal aortic aneurysm: a multicentre cohort study. Eur J Emerg Med. 2016;23(5).CrossRef

69.

Sakalihasan N, Limet R, Defawe OD. Abdominal aortic aneurysm. Lancet. 2005;365(9470):1577–89. https://doi.org/10.1016/S0140-6736(05)66459-8.CrossRefPubMed

70.

Craxford S, Bayley E, Walsh M, Clamp J, Boszczyk BM, Stokes OM. Missed cervical spine injuries. Bone Joint J. 2016;98-B(6):825.CrossRef

71.

Michaleff ZA, Maher CG, Verhagen AP, Rebbeck T, Lin C-WC. Accuracy of the Canadian C-spine rule and NEXUS to screen for clinically important cervical spine injury in patients following blunt trauma: a systematic review. Can Med Assoc J. 2012.

72.

Runciman B, Merry A, Walton M. Safety and ethics in healthcare: a guide to getting it right. 1st ed. London: Taylor and Francis; 2007.

73.

Dixon-Woods M, Pronovost PJ. Patient safety and the problem of many hands. BMJ Qual Saf. 2016.

74.

McGlynn EA, McDonald KM, Cassel CK. Measurement is essential for improving diagnosis and reducing diagnostic error: a report from the institute of medicine. JAMA. 2015;314(23):2501–2. https://doi.org/10.1001/jama.2015.13453.CrossRefPubMed

75.

Brook OR, O’Connell AM, Thornton E, Eisenberg RL, Mendiratta-Lala M, Kruskal JB. Quality initiatives: anatomy and pathophysiology of errors occurring in clinical radiology practice. RadioGraphics. 2010;30(5):1401–10. https://doi.org/10.1148/rg.305105013.CrossRefPubMed

76.

Shannon SE. Ebola, team communication, and shame: but shame on whom? Am J Bioeth. 2015;15(4):20–5. https://doi.org/10.1080/15265161.2015.1010998.CrossRefPubMed

77.

Newman-Toker DE, Pronovost PJ. Diagnostic errors—the next frontier for patient safety. JAMA. 2009;301(10):1060–2. https://doi.org/10.1001/jama.2009.249.CrossRefPubMed

Title: Diagnostic error in the emergency department: learning from national patient safety incident report analysis
Authors: Faris Hussain
Alison Cooper
Andrew Carson-Stevens
Liam Donaldson
Peter Hibbert
Thomas Hughes
Adrian Edwards
Publication date: 01-12-2019
Publisher: BioMed Central
Published in: BMC Emergency Medicine / Issue 1/2019
Electronic ISSN: 1471-227X
DOI: https://doi.org/10.1186/s12873-019-0289-3

Keynote webinar | Spotlight on sleep in brain health

Springer Medicine

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

Abstract

Background

Methods

Results

Conclusions

Keynote webinar | Spotlight on sleep in brain health

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

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