Diagnostic errors in ambulatory care: dimensions and preventive strategies.

Patient Safety in Ambulatory Care

Efforts to improve patient safety have largely focused on inpatient or emergency settings, but the importance of patient safety in ambulatory care is increasingly being recognized as a key component of overall health care quality. Care gaps in outpatient settings may include missed diagnoses, medication errors, or insufficient monitoring of patients with chronic conditions or on certain medications. Further, care gaps may occur across a wide range of clinical conditions. We report here an innovative approach to improve patient safety in ambulatory settings – the Kaiser Permanente Southern California (KPSC) Outpatient Safety Net Program – which leverages electronic health information to efficiently identify and address a variety of potential care gaps across different clinical conditions.Between 2006 and 2012, the KPSC Outpatient Safety Net Program implemented 24 distinct electronic clinical surveillance programs, which routinely scan the electronic health record to identify patients with a particular condition or event. For example, electronic clinical surveillance may be used to scan for harmful medication interactions or potentially missed diagnoses (e.g., abnormal test results without evidence of subsequent care). Keys to the success of the program include strong leadership support, a proactive clinical culture, the blame-free nature of the program, and the availability of electronic health information. The Outpatient Safety Net Program framework may be adopted by other organizations, including those who have electronic health information but not an electronic health record. In the future, the creation of a forum to share electronic clinical surveillance programs across organizations may facilitate more rapid improvements in outpatient safety.

PATIENT SAFETY HAS BEEN A TOPIC OF CONSIDERABLE interest over the last decade, with evidence showing that medical errors are responsible for substantial morbidity and mortality. There has been significant progress in understanding, identifying, and addressing errors at a system level; however, the performance of individual clinicians remains a crucial and largely unaddressed element of patient safety. Individual performance is important in diagnostic errors, but these errors are difficult to measure and have received little systematic study. Diagnostic errors often stem from cognitive biases, also referred to as “cognitive dispositions to respond” (CDRs). Because CDRs are integral to human cognition, they are challenging to overcome. Croskerry has delineated more than 30 CDRs and has proposed “debiasing strategies” to prevent errors due to CDRs. Prominent among these strategies is metacognition, or an individual’s knowledge of his or her own thinking process. Notably, there is significant overlap between metacognition and mindfulness, nonjudgmental awareness of the present moment. Increased mindfulness leads to greater awareness and understanding of a person’s experiences, including thoughts, emotions, and bodily sensations. Because education can increase mindfulness, mindfulness instruction for clinicians holds promise as a debiasing strategy for reducing diagnostic and other medical errors.

Electronic prescribing systems with decision support may improve patient safety in ambulatory care by offering drug allergy and drug interaction alerts. However, preliminary studies show that clinicians override most of these alerts. We performed a retrospective analysis of 233 537 medication safety alerts generated by 2872 clinicians in Massachusetts, New Jersey, and Pennsylvania who used a common electronic prescribing system from January 1, 2006, through September 30, 2006. We used multivariate techniques to examine factors associated with alert acceptance. A total of 6.6% of electronic prescription attempts generated alerts. Clinicians accepted 9.2% of drug interaction alerts and 23.0% of allergy alerts. High-severity interactions accounted for most alerts (61.6%); clinicians accepted high-severity alerts slightly more often than moderate- or low-severity interaction alerts (10.4%, 7.3%, and 7.1%, respectively; P < .001). Clinicians accepted 2.2% to 43.1% of high-severity interaction alerts, depending on the classes of interacting medications. In multivariable analyses, we found no difference in alert acceptance among clinicians of different specialties (P = .16). Clinicians were less likely to accept a drug interaction alert if the patient had previously received the alerted medication (odds ratio, 0.03; 95% confidence interval, 0.03-0.03). Clinicians override most medication alerts, suggesting that current medication safety alerts may be inadequate to protect patient safety.

Patient Safety: Grantmakers Join The Effort To Reduce Medical Errors

&lt;p dir="ltr"&gt;For correction of large dentofacial deformities orthognathic surgery is performed. Treatment in the maxilla, mandible or as bimaxillary surgery, and by tradition in inpatient care (IPC). Mandibular fractures, unlike mandibular orthognathic surgical procedures, are mainly treated in outpatient care (OPC). There are studies showing that good patient satisfaction and few unexpected complications were achieved with orthognathic surgery in OPC. In times of strained healthcare finances as a result of, e.g., a growing elderly population with increased need for healthcare, with rising costs for medical technology innovations and drugs, and with long care queues for specialist care and operation, it is of utmost importance that healthcare resources are organised and prioritised responsibly and as cost-efficiently as possible. Complications connected with surgical procedures not only cause suffering for the patient with a risk of affecting the outcome but also are resource-intensive and burdensome for both the health economy and society. This thesis compares OPC and IPC single-jaw orthognathic surgery with respect to patient safety and cost, and identifies factors that may predict postoperative complications of orthognathic surgery.&lt;/p&gt;&lt;p dir="ltr"&gt;Study I and II (n = 165) included patients operated with single-jaw orthognathic surgery (i.e., SARME, LF1, and BSSO) in OPC and IPC. Outcome in Study I was patient safety (i.e., complications, emergency visits, emergency phone calls, admission of patients operated in OPC, and re-admission of already discharged patients) after orthognathic surgery in OPC and IPC the first 12 months postoperatively. The outcomes in Study II were calculated costs (including orthognathic surgery, return visits, emergency visits, emergency phone calls, removal of osteosynthesis material, and re-operations) in OPC and IPC within 12 months after surgery.&lt;/p&gt;&lt;p dir="ltr"&gt;Study III (n = 428) included patients registered in the National Registry of Orthognathic Surgery (NROK). Patient-specific and surgery-specific factors were analysed to identify risk factors for postoperative complications after orthognathic surgery.&lt;/p&gt;&lt;p dir="ltr"&gt;Study I found that 101 of 107 patients (94.4%) operated in OPC were discharged day of surgery. There were no significant differences between treatment in OPC and IPC regarding number of emergency visits and emergency phone calls per patients, postoperative bleeding, postoperative pain, plate removal, and re- operations, but an increased risk of POI, about 2.5 times, was detected in the OPC group.&lt;/p&gt;&lt;p dir="ltr"&gt;Study II found that the total mean cost (e.g., revisits, emergency visits, and emergency phone calls) over 12 months were 34.2% lower for SARME, 48.8% lower for LF1, and 38.3% lower for BSSO in OPC than in IPC. 130 days were used at the inpatient ward for the IPC group.&lt;/p&gt;&lt;p dir="ltr"&gt;Study III showed that surgical site was the factor most clearly associated with postoperative complications after orthognathic surgery. Compared to maxillary surgery, single-jaw mandible surgery (e.g., BSSO) and bimaxillary surgery increased the risk of POI, removal of osteosynthesis material, and neurosensory deficit (NSD) by more than three times. For re-operations, there were no significant differences in risk between surgery in the maxilla, mandible, or bimaxillary surgery. Overweight (BMI&gt;25.5 - 30.0), age over 40, smoking and no postoperative antibiotics were other factors increasing the risk for postoperative complications.&lt;/p&gt;&lt;p dir="ltr"&gt;In conclusion, the results in this thesis show that operation of selected single-jaw orthognathic surgery can be performed with maintained patient safety in OPC, but the high rate of POI in the OPC group needs further study. The costs of performing SARME, LF1, and BSSO are associated with significantly lower healthcare costs in OPC than in IPC. Moreover, the transition to OPC will release resources for patients in more urgent need. Complications after orthognathic surgery are mainly associated with interventions in the lower jaw and with bimaxillary surgery, which should be considered before surgery.&lt;/p&gt;&lt;h3&gt;List of scientific papers&lt;/h3&gt;&lt;p dir="ltr"&gt;I. &lt;b&gt;Pekkari C,&lt;/b&gt; Weiner CK, Marcusson A, Davidson T, Naimi-Akbar A and Lund B. Patient safety with orthognathic surgery in an outpatient setting. Int J Oral Maxillofac Surg. 2023; 52: 806-12. &lt;a href="https://doi.org/10.1016/j.ijom.2022.12.001" rel="noreferrer" target="_blank"&gt;https://doi.org/10.1016/j.ijom.2022.12.001&lt;/a&gt;&lt;/p&gt;&lt;p dir="ltr"&gt;II. &lt;b&gt;Pekkari C,&lt;/b&gt; Lund B, Davidson T, Naimi-Akbar A, Marcusson A and Weiner CK. Cost analysis of orthognathic surgery: outpatient care versus inpatient care. Int J Oral Maxillofac Surg. 2024; 53: 829-35. &lt;a href="https://doi.org/10.1016/j.ijom.2024.02.005" rel="noreferrer" target="_blank"&gt;https://doi.org/10.1016/j.ijom.2024.02.005&lt;/a&gt;&lt;/p&gt;&lt;p dir="ltr"&gt;III. &lt;b&gt;Pekkari C,&lt;/b&gt; Weiner CK, Salinas Fredricson A, Lund B, Marcusson A and Naimi-Akbar A. Risk factors for postoperative complications in a cohort of Swedish orthognathic patients - The National Registry of Orthognathic Surgery (NROK). [Submitted]&lt;/p&gt;

Accurate diagnosis is critical for patient safety, guiding treatment and preventing harm. Diagnostic errors remain prevalent, contributing to avoidable harm, increased healthcare costs, and morbidity. Understanding diagnostic accuracy is essential to improving clinical outcomes. This review aims to systematically explore the impact of accurate diagnosis on patient safety, identifying challenges in current diagnostic practices and strategies for improvement. A comprehensive search of PubMed, CINAHL, the Cochrane Library, and Google Scholar was conducted from 2010-2024. Initial screening yielded 579 records, using keywords like "accurate diagnosis", "diagnostic errors", and "patient safety." A full-text review of 125 studies was conducted after duplicates were eliminated and titles and abstracts were screened for relevancy. Exclusion criteria excluded studies with inadequate data, non-English publications, and opinion pieces, while inclusion criteria mandated that studies concentrate on patient safety and diagnostic accuracy in acute care settings. Ultimately, 26 studies were found to meet the final eligibility requirements and were added to the review. Retrospective cohort studies and randomized controlled trials were among the study designs. Accurate diagnosis was found to improve treatment efficacy, enhances patient safety, and reduces unnecessary procedures. Challenges include cognitive biases, insufficient diagnostic tools, and fragmented care. Technological advancements, including artificial intelligence (AI) and machine learning, were found to significantly enhance diagnostic precision. Despite these benefits, variability in clinical skills and systemic barriers remain substantial obstacles. Accurate diagnosis is essential to enhancing patient safety. The results of this review indicate that using AI tools, improving clinician training, and creating standardized diagnostic procedures may help reduce diagnostic errors; however, because of the small dataset and lack of meta-analysis, the findings should be interpreted cautiously. To further evaluate the effect of diagnostic accuracy on patient safety, future research should concentrate on carrying out larger-scale studies and statistical validations.

Objectives Medical litigation resulting from diagnostic errors leads to lawsuits that are time-consuming, expensive, and psychologically burdensome. Few studies have focused on internists, who are more likely to make diagnostic errors than others, with assessments of litigation in terms of system and diagnostic errors. This study explored factors contributing to internists losing lawsuits and examined whether system or diagnostic errors were more important on the outcome. Methods Data regarding 419 lawsuits against internists closed between 1961 and 2017 were extracted from a public Japanese database. Factors affecting litigation outcomes were identified by comparative analysis focusing on system and diagnostic errors, environmental factors, and differences in initial diagnoses. Results Overall, 419 malpractice claims against internists were analyzed. The rate of lawsuits being decided against internists was high (50.1%). The primary cause of litigation was diagnostic errors (213, 54%), followed by system errors (188, 45%). The foremost initial diagnostic error was “no abnormality” (17.2%) followed by ischemic heart disease (9.6%) and malignant neoplasm (8.1%). Following cause-adjustment for loss, system errors were 21.37 times more likely to lead to a loss. Losses were 6.26 times higher for diagnostic error cases, 2.49 times higher for errors occurring at night, and 3.44 times higher when “malignant neoplasm” was the first diagnosis. Conclusions This study found that system errors strongly contributed to internists' losses. Diagnostic errors, night shifts, and initial diagnoses of malignant neoplasms also significantly affected trial outcomes. Administrators must focus on both system errors and diagnostic errors to enhance the safety of patients and reduce internists' risk exposure.

Diagnostic Errors in Medicine: A Case of Neglect

A retrospective review of 100 sequential patients (2009-2012) with head and neck cancer was performed to determine the frequency of 5 types of diagnostic delays and errors outlined by the Institute of Medicine. There were a total of 105 diagnostic delays/errors. The most common was delay in being seen in the otolaryngology clinic after referral placement (28.6%), followed by diagnostic error by the referring physician (22%), delay in referral of a symptomatic patient to the otolaryngology clinic (16.2%), delay in employing an appropriate diagnostic test or procedure (15.2%), delay in action following reporting of pathology or imaging results for an incidental lesion (11.4%), diagnostic error by the otolaryngology clinic (2.8%), delay in action following reporting of pathology or imaging results for the symptomatic lesion (2.8%), and use of outmoded tests or therapy (1%). Increased awareness of these types of delays/errors will direct actions and processes to reduce or eliminate them.

To assess frequency and severity of patient safety incidents in primary care. Cross-sectional survey of health-care professionals in Swiss primary care offices. Physicians and nurses in primary care offices were surveyed about the frequency and severity of 23 safety incidents. Differences between professional groups and types of offices were analyzed. Reported incidents were classified in a matrix. A total of 630 individuals (50.2% physicians, 49.8% nurses) participated. Among them, 30% of physicians (95% confidence interval [CI] 25%-35%) and 16.6% of nurses (95% CI 12%-21%) reported that at least 1 of the incidents occurred daily or weekly in their offices (c2 16.1, P <.001). On average, each responder reported a total of 92 incidents during the preceding 12 months (mean of 117 events for physicians, mean of 66 events for nurses; P <.001). Documentation failure was reported most frequently.The highest fraction of last occurrences with severe injury or death was for diagnostic errors (4.1%). Unadjusted for caseload, staff working in medical centers reported higher frequencies of several incidents. The frequency-harm matrix suggests that triage by nurse at initial contact, diagnostic errors, medication errors, failure to monitor patients after medical procedures, and test or intervention errors should be prioritized for action. This study presents a supplemental approach to identification of safety threats in primary care. Many incidents occur regularly and are highly relevant for healthcare professionals' daily work.The results offer guidance on setting priorities for patient safety in primary care.

Diagnostic errors comprise a critical subset of medical errors and often stem from errors in individual cognition. While traditional patient safety methods for dissecting medical errors focus on faulty systems, such methods are often less useful in cases of diagnostic error, and a broader cognitive framework is needed to ensure a comprehensive analysis of these complex events. The fishbone diagram is a widely utilized patient safety tool that helps to facilitate root cause analysis discussions. This tool was expanded by the authors to reflect the contributions of both systems and individual cognitive errors to diagnostic errors. We describe how two medical centers have applied this modified fishbone diagram to approach diagnostic errors in a way that better meets the patient safety and educational needs of their respective institutions.

Background: No previous studies have investigated whether medical emergency team (MET) responses can be used to detect medical errors. Objectives: To determine whether review of MET responses can be used...

BackgroundThe fast turnaround time and user-friendliness of point-of-care tests (POCTs) offer a great potential to improve outpatient health care where clinical decisions have to be made during the physician-patient encounter and time resources are limited. The aim of this scoping review is to describe the extent and nature as well as gaps in German research activities on POCT in outpatient care. In addition, we define research endpoints that should be addressed in the comprehensive evaluation of POCTs targeted for outpatient care. MethodsWe performed a scoping review with a systematic literature search in Medline (via PubMed), Scopus, Web of Science, Cochrane library and Google Scholar for German publications on POCT with relevance to German outpatient care published from January 2005 to November 2020. ResultsOur literature search identified 2,200 unique records. After literature selection 117 articles were included in this scoping review. Just over half of the articles (67/117, 57.3%) were primary research studies with original data, while one third of all the studies (33.3%) were secondary research articles (e.g., review articles). The remaining articles were clinical recommendations / position papers (7/117, 6.0%) and other types of articles (3.4%). The majority of articles focused on POCT use in infectious diseases (44/117, 37.6%), diabetic syndromes (15.4%), cardiac disease (12.0%) or coagulopathies and thrombosis (10.3%), while the remaining articles did not specify the disease (13.7%) or investigated other diseases (11.1%). Similar to international studies, most primary research studies investigated the diagnostic performance of POCT (e.g., sensitivity, specificity). Evidence beyond diagnostic accuracy remains scarce, such as the impact on therapeutic decisions and practice routines, clinical effectiveness, and user perspectives. In line with this, interventional studies (such as RCTs) on the effectiveness of POCT use in German outpatient care are limited. We define six endpoint domains that should be addressed in the evaluation of POCTs targeted for outpatient care: (i) diagnostic performance, (ii) clinical performance, (iii) time and costs, (iv) impact on clinical routines / processes, (v) perspectives of medical professionals and patients, and (vi) broader aspects. ConclusionThere is considerable research activity on POCTs targeted for use in outpatient care in Germany. Data on their potential benefits beyond diagnostic accuracy is often lacking and should be addressed in future POCT research studies.

Error-reporting systems are widely regarded as critical components to improving patient safety, yet current systems do not effectively engage patients. We sought to assess Twitter as a source to gather patient perspective on errors in this feasibility study. We included publicly accessible tweets in English from any geography. To collect patient safety tweets, we consulted a patient safety expert and constructed a set of highly relevant phrases, such as "doctor screwed up." We used Twitter's search application program interface from January to August 2012 to identify tweets that matched the set of phrases. Two researchers used criteria to independently review tweets and choose those relevant to patient safety; a third reviewer resolved discrepancies. Variables included source and sex of tweeter, source and type of error, emotional response, and mention of litigation. Of 1006 tweets analyzed, 839 (83%) identified the type of error: 26% of which were procedural errors, 23% were medication errors, 23% were diagnostic errors, and 14% were surgical errors. A total of 850 (84%) identified a tweet source, 90% of which were by the patient and 9% by a family member. A total of 519 (52%) identified an emotional response, 47% of which expressed anger or frustration, 21% expressed humor or sarcasm, and 14% expressed sadness or grief. Of the tweets, 6.3% mentioned an intent to pursue malpractice litigation. Twitter is a relevant data source to obtain the patient perspective on medical errors. Twitter may provide an opportunity for health systems and providers to identify and communicate with patients who have experienced a medical error. Further research is needed to assess the reliability of the data.