Use of a novel, modified fishbone diagram to analyze diagnostic errors.

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.

Patient Safety: Grantmakers Join The Effort To Reduce Medical Errors

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.

A Systems Approach to Morbidity and Mortality Conference

Patient safety aims to achieve healthcare free of damage. The World Health Organization indicates that this objective is achieved through communication, analysis, and prevention of adverse events in patients. Organizational culture has been identified as one of the main factors for interventions aimed to reduce medical errors; and an essential component of safety culture is the attitude of health professionals towards medical error. Attitudes can be improved through appropriate education in biomedical careers but its inclusion in Argentina is scarce. The Attitudes Questionnaire for Patient Safety, measures knowledge, beliefs, and attitudes about patient safety and could be a useful tool in our country. To validate the modified attitudes for patient safety questionnaire to measure knowledges, beliefs, and attitudes of medical students at CEMIC University Institute. To describe the level of knowledges, beliefs, and attitudes in patient safety of medical students at CEMIC University Institute in 2012, 2015 and 2016. Design: descriptive study. Scope: Exploratory. Setting: the CEMIC University Institute in Buenos Aires, Argentina. Population: medical students of 4th and 5th year. Sampling: a sample size of 100 participants was estimated to derive meaningful estimates as per a Cronbach's alpha> 0.60. The reliability of the instrument (internal consistency) by Cronbach's alpha showed an overall correlation of 0.695. Suitable Cronbach's alpha values were obtained in all categories, except in two: importance of patient safety in the curriculum and the inevitability of error. The responses on knowledge, attitudes and perceptions about patient safety in the three cohorts showed that 57% of students believe they understand concepts about patient safety, 53% consider their training prepares them to understand the cause of medical errors, only 59% believe that human error is inevitable and 98% believe that real professionals do not make mistakes. Lastly, 64% believe that this knowledge is only acquired from clinical experience. This study shows that the APSQ-III modified survey is valid and could be used in Argentina and the region to measure the impact of incorporating patient safety topics in the medical curriculum.

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.

Despite an increasing focus on patient safety in ambulatory care, progress in understanding and reducing diagnostic errors in this setting lag behind many other safety concerns such as medication errors. To explore the extent and nature of diagnostic errors in ambulatory care, we identified five dimensions of ambulatory care from which errors may arise: (1) the provider-patient encounter, (2) performance and interpretation of diagnostic tests, (3) follow-up of patients and diagnostic test results, (4) subspecialty consultation, and (5) patients seeking care and adhering to their instruction/appointments, i.e. patient behaviors. We presented these risk domains to conference participants to elicit their views about sources of and solutions to diagnostic errors in ambulatory care. In this paper, we present a summary of discussion in each of these risk domains. Many novel themes and hypotheses for future research and interventions emerged.

Cognitive science has made tremendous strides in recent decades. Through its contributions, we have gained insights that have informed both clinicians and basic scientists. In addition, it has provided important contributions in the area of patient safety and the factors that may contribute to the occurrence of adverse events. The impact of these contributions can be viewed from patient, clinician, and care environment perspectives. Several examples will illustrate the types of insights that can be gained to improve patient safety. Patient behavior is one important area that would benefit from cognitive science. When medication errors occur, often the focus is on clinician behaviors and performance; the importance of patient characteristics and behaviors often is overlooked. A recent study examined the complexity of medication instructions and the factors associated with patients' understanding of prescription drug warning labels. Findings indicate that comprehension of warning labels by patients was associated with patient literacy levels. Patients with low literacy levels were three to four times less likely to interpret prescription medication warnings correctly. In addition, multistep instructions were difficult across all literacy levels (Davis et al., 2006). Given the fact that patients are increasingly managing multiple prescriptions and over-the-counter medications, this study has important implications from both cognition and safety perspectives. Although the study did not examine other aspects of cognitive function, it suggests that more research is needed to ensure that factors that influence patients' adherence with medication regimens is needed to ensure safe patient self-management. Clinical simulations can be used for a variety of purposes. The effectiveness of simulations in research around sleep deprivation and implications for decision-making in patient care situations have been described (Howard et al., 2003). Researchers used an experimental design to measure the performance of anesthesiology residents under normal and sleep-deprived conditions. Psychomotor performance and mood in the sleep-deprived residents were impaired. Although simulations may not be identical to real patient care situations, the results support the thesis that cognitive processes are impaired in clinical decision-making situations when clinicians are sleep deprived. This certainly provides a safe, controlled environment in which actual mistakes will not jeopardize patients. One only has to imagine a staff nurse working a second consecutive shift under a mandatory overtime requirement due to the nursing shortage to envision the effects of sleep deprivation among nurses. Cioffi (2001) describes how simulation can be used for research and education to assess learning and performance in skill areas that would be directly transferable to real clinical situations. Methods are available to measure both validity and reliability. Use of simulations would provide an opportunity for research without compromising either scientific rigor or provider and patient safety. Croskerry (2003) approaches patient safety from a cognitive science perspective, describing various cognitive dispositions to respond to decision-making situations as demonstrated by physicians. Diagnostic errors by clinicians can occur through a variety of cognitive dispositions, including cognitive errors, failed perceptions, biases, and failed heuristics. Potential for reducing cognitive diagnostic errors has been demonstrated using metacognition, a reflective approach that involves stepping back from an immediate decision-making situation to examine and reflect on the thinking processes. This approach would appear to have direct implications and research potential for decision-making by nurses and other clinicians as well. …

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.

Strive for Excellence, Not Perfection

In June 2004, an article in American Journal of Nursing reported findings of a three-year study of organizational culture, attitudes, and assignment of responsibility for patient safety in small, rural hospitals in nine Western states. The study found that most errors fall within realm of nursing practice and that physicians, administrators, and nurses themselves tend to see patient safety as largely a nursing responsibility. Asked to identify which profession has primary responsibility for ensuring patient safety, 96 percent of nurses and more than 90 percent of physicians, administrators, and pharmacists assigned primary responsibility to nurses. Only 22 percent of respondents believed that physicians, nurses, pharmacists, and administrators share responsibility for patient safety equally. Unfortunately, however, nurses and physicians differed on role of nurses in effecting change. Most of nurses indicated that they had several responsibilities in reducing medical errors, including reporting them, educating themselves and colleagues, serving as role models, making recommendations for changes in procedure and policy, reviewing reported adverse patient-safety events, and participating in investigations. Only 8 percent of physicians who responded to survey identified nurses as members of decisionmaking team. Nurses have a genuine impact on patient safety. Studies have found a link between patient safety and RN staffing and an increased rate of error when hospital nursing staff has a smaller proportion of RNs. These are worrisome findings in light of severe national shortage of nurses. Part of medical malpractice crisis, then, is confusion in health care system and how it affects role of nurse. There is no confusion in American Nurses Association's code of ethics. This document, first adopted in 1950 and revised in 2001 to reflect and embrace role of today's nurse, consists of a set of planks that set out nurses' fundamental values and commitments. They also offer a starting point for understanding how nurses should be involved in thinking about medical error, and why nurses blame themselves for medical errors. The first few planks are most important. These planks state that nurse's primary commitment is to patient (plank 2), and that nurse promotes, advocates for, and strives to protect health, safety, and rights of patient (plank 3). Interpretive Statements that accompany code add that nurses are committed to patient's health, well-being, and safety throughout patient's life span, and in all settings in which health care needs are addressed. Further, code directs that, as an advocate for patient, the nurse must take appropriate actions regarding any instances of incompetent, unethical, and illegal practice by any member of health care team or health care system or any action on part of others that places rights or best interest of patient in jeopardy. For nurses to function effectively in this role, they must be knowledgeable about code of ethics, standards of practice, relevant laws, and their own organization's policies and procedures. Moreover, when nurse is aware of inappropriate or questionable practice in provision or denial of health care, concerns should be expressed to person engaging in questionable practice. Attention should be called to possible detrimental effect upon patient's well-being or best interests, as well as to integrity of nursing practice. When factors in health care delivery system or health care organization threaten welfare of patient, concerns should be directed to responsible administrator. If indicated, problem should be reported to an appropriate higher authority within institution or agency, or to an appropriate external authority. The interpretive statements for third plank also remind nurses that they have a responsibility to implement and maintain standards of professional nursing practice. …

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...

Introduction:Patient safety is essential to healthcare quality. Its deficiencies impact health outcomes, quality of life, healthcare effectiveness and efficiency. Its improvement should be a priority for any country particularly developing countries like Nigeria. However, the emergence of “Covid-19”, the inadequacy of healthcare facilities and the prevalence of diagnostic errors have complicated efforts to improve patient safety in Nigeria.Materials and Methods:This research adopts a qualitative research approach, specifically text analysis, to review the literature on the subject. A review of the literature revealed a number of diagnostic issues which threaten patient safety. Existing literature on misdiagnosis, inaccurate, delayed, missed, and remote diagnosis, as well as the relationship between the adequacy of healthcare facilities and the advancement of patient safety, was reviewed and analyzed.Results:This paper finds that Patient safety cannot be guaranteed in the absence of an accurate diagnosis, access to secure infrastructure, appropriate technologies and medical devices, as well as a qualified and dedicated health workforce, among other factors. Early detection of diseases in general, and Covid-19 in particular, improves patient safety and lowers mortality rates. Inadequate healthcare facilities, diagnostic equipment, diagnostic errors, and disease information, on the other hand, make early detection difficult and have a negative impact on patient safety.Conclusion:There is a need for early and accurate diagnosis of Covid-19 and this can only be achieved with adequate healthcare facilities including diagnostic equipment and laboratories. As a result, there will be fewer diagnostic errors, more effective patient management and treatment, and, ultimately, improved patient safety.

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.

ObjectivesTo investigate what healthcare professionals perceived and experienced as key patient safety concerns in Bhutan’s healthcare system.DesignQualitative exploratory descriptive inquiry.SettingsThree different levels of hospitals, a training institute and the Ministry...