Published by De Gruyter

Volume 1 Issue 2

Issue of Diagnosis

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Publicly Available May 21, 2014

Editorials

Open Access April 11, 2014

A missed opportunity – a near disaster

Jack M. Rubenstein

Page range: 143-143

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Open Access May 21, 2014

Diagnostic error in community-acquired pneumonia

Robert M. Centor, Rajashekar Kumar

Page range: 145-145

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Opinion Papers

Open Access April 22, 2014

A missed opportunity—a near disaster

George A. Sarosi

Page range: 147-149

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Abstract

Community acquired pneumonia (CAP) is a common medical problem. Over 1.5 million patients annually will be diagnosed with CAP and treated with empiric therapy initially. The vast majority of patients will improve with a single course broad spectrum antimicrobial agent. Rarely a patient will not improve and some may progress on this regimen. Giving a second course of broad spectrum antimicrobial agent is not warranted until further evaluation is performed to look for the unusual cause of CAP. Blastomycosis is a regionally common community acquired fungal infection. When potential exposure of the patient to an area of high endemicity is recognized appropriate diagnostic studies should be performed.

Open Access April 12, 2014

Defensive medicine and diagnostic testing

Mario Plebani

Page range: 151-154

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Abstract

Defensive medicine often involves the excessive ordering of diagnostic tests. Constantly aware of the risk of malpractice liability, physicians turn to diagnostic tests with the goal of reducing the likelihood of error. Findings reported in literature suggest that medical malpractice contributes significantly to the increased use of diagnostic testing and related costs. It has also been demonstrated that defensive testing not only increases costs but harms patients to a degree that depends on the risk incurred by the test itself, its false-positive and false-negative rates, the benefits and risks of available therapies, and the prior probability of disease. Several solutions have been proposed in the attempt to address this issue, but the physician’s competence and training appear to be key factors, data from clinical trials showing that education and feedback for improving test-ordering tendencies have a prolonged effect. Particularly in the field of laboratory medicine, increasing attention is being paid to improving demand management in order to minimize inappropriate testing.

Original Articles

Open Access April 3, 2014

Missed diagnosis of stroke in the emergency department: a cross-sectional analysis of a large population-based sample

David E. Newman-Toker, Ernest Moy, Ernest Valente, Rosanna Coffey, Anika L. Hines

Page range: 155-166

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Abstract

Background: Some cerebrovascular events are not diagnosed promptly, potentially resulting in death or disability from missed treatments. We sought to estimate the frequency of missed stroke and examine associations with patient, emergency department (ED), and hospital characteristics. Methods: Cross-sectional analysis using linked inpatient discharge and ED visit records from the 2009 Healthcare Cost and Utilization Project State Inpatient Databases and 2008–2009 State ED Databases across nine US states. We identified adult patients admitted for stroke with a treat-and-release ED visit in the prior 30 days, considering those given a non-cerebrovascular diagnosis as probable (benign headache or dizziness diagnosis) or potential (any other diagnosis) missed strokes. Results: There were 23,809 potential and 2243 probable missed strokes representing 12.7% and 1.2% of stroke admissions, respectively. Missed hemorrhages (n=406) were linked to headache while missed ischemic strokes (n=1435) and transient ischemic attacks (n=402) were linked to headache or dizziness. Odds of a probable misdiagnosis were lower among men (OR 0.75), older individuals (18–44 years [base]; 45–64:OR 0.43; 65–74:OR 0.28; ≥75:OR 0.19), and Medicare (OR 0.66) or Medicaid (OR 0.70) recipients compared to privately insured patients. Odds were higher among Blacks (OR 1.18), Asian/Pacific Islanders (OR 1.29), and Hispanics (OR 1.30). Odds were higher in non-teaching hospitals (OR 1.45) and low-volume hospitals (OR 1.57). Conclusions: We estimate 15,000–165,000 misdiagnosed cerebrovascular events annually in US EDs, disproportionately presenting with headache or dizziness. Physicians evaluating these symptoms should be particularly attuned to the possibility of stroke in younger, female, and non-White patients.

Open Access April 11, 2014

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

James B. Reilly, Jennifer S. Myers, Doug Salvador, Robert L. Trowbridge

Page range: 167-171

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Abstract

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.

Open Access April 12, 2014

Failure mode effects and criticality analysis: innovative risk assessment to identify critical areas for improvement in emergency department sepsis resuscitation

Emilie S. Powell, Lanty M. O’Connor, Anna P. Nannicelli, Lisa T. Barker, Rahul K. Khare, Nicholas P. Seivert, Jane L. Holl, John A. Vozenilek

Page range: 173-181

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Abstract

Background: Sepsis is an increasing problem in the practice of emergency medicine as the prevalence is increasing and optimal care to reduce mortality requires significant resources and time. Evidence-based septic shock resuscitation strategies exist, and rely on appropriate recognition and diagnosis, but variation in adherence to the recommendations and therefore outcomes remains. Our objective was to perform a multi-institutional prospective risk-assessment, using failure mode effects and criticality analysis (FMECA), to identify high-risk failures in ED sepsis resuscitation. Methods: We conducted a FMECA, which prospectively identifies critical areas for improvement in systems and processes of care, across three diverse hospitals. A multidisciplinary group of participants described the process of emergency department (ED) sepsis resuscitation to then create a comprehensive map and table listing all process steps and identified process failures. High-risk failures in sepsis resuscitation from each of the institutions were compiled to identify common high-risk failures. Results: Common high-risk failures included limited availability of equipment to place the central venous catheter and conduct invasive monitoring, and cognitive overload leading to errors in decision-making. Additionally, we identified great variability in care processes across institutions. Discussion: Several common high-risk failures in sepsis care exist: a disparity in resources available across hospitals, a lack of adherence to the invasive components of care, and cognitive barriers that affect expert clinicians’ decision-making capabilities. Future work may concentrate on dissemination of non-invasive alternatives and overcoming cognitive barriers in diagnosis and knowledge translation.

Open Access April 11, 2014

Path dependence and routines: a threat to capability development

Lars E. Sjödahl

Page range: 183-188

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Abstract

This article introduces the concept path dependence based on case illustrations mainly from psychiatric health care. The concept path dependence is widely used in economic research, history, social sciences and law, but so far seldom in psychology and health care, although equally applicable here. Two variants of path dependence, one in a narrow sense and one in a broader sense are defined and exemplified by case illustrations from psychiatric health care and patient safety systems.

Open Access May 21, 2014

Diagnostic conversations: Clinical Decision Making in surgery – Part 2

David Allan Watters, Spencer Wynyard Beasley, Wendy Crebbin

Page range: 189-193

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Abstract

Proceduralists who fail to review their decision making are unlikely to learn from their experiences, irrespective of whether the operative outcome is successful or not. Teaching junior surgeons to develop ‘insight’ into their own decision making has long been a challenge. Surgeons and staff of the Royal Australasian College of Surgeons worked together to develop a model to help explain the processes around clinical decision making and incorporated this model into a Clinical Decision Making (CDM) training course. In this course, faculty apply the model to specific surgical cases, within the model’s framework of how clinical decisions are made; thus providing an opportunity to identify specific decision making processes as they occur and to highlight some of the learning opportunities they provide. The conversation in this paper illustrates the kinds of case-based interactions which typically occur in the development and teaching of the CDM course.The focus in this, the second of two papers, is on reviewing post-operative clinical decisions made in relation to one case, to improve the quality of subsequent decision making.

Letter to the Editor

Open Access February 27, 2014

Analytical assessment of the Beckman Coulter Unicel DxI AccuTnI+3 immunoassay

Giuseppe Lippi, Mariella Dipalo, Paola Avanzini, Alessandro Formentini, Rosalia Aloe

Page range: 195-197

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About this journal

Objective
Diagnosis is a subscription journal, which focuses on how diagnosis can be advanced, how it is taught, and how and why it can fail, leading to diagnostic errors. The journal welcomes both fundamental and applied works, improvement initiatives, opinions, and debates to encourage new thinking on improving this critical aspect of healthcare quality. Diagnosis is the official journal of the Society to Improve Diagnosis in Medicine.

Please submit your manuscript here

Topics

Factors that promote diagnostic quality and safety
Clinical reasoning
Diagnostic errors in medicine
The factors that contribute to diagnostic error: human factors, cognitive issues, and system-related breakdowns
Improving the value of diagnosis – eliminating waste and unnecessary testing
How culture and removing blame promote awareness of diagnostic errors
Training and education related to clinical reasoning and diagnostic skills
Advances in laboratory testing and imaging that improve diagnostic capability
Local, national and international initiatives to reduce diagnostic error

Article formats

Research Reports – Reports of original research
Short Communications – Reports of early research results and pilot studies
Reviews – Systematic, narrative, and focused reviews. Review articles are normally published by invitation, but suggestions to the Editors are welcome
Opinion Papers and Editorials
Letters to the Editor
Point/Counterpoint Papers
Guidelines and Recommendations
Innovations in diagnostic testing – Advances in laboratory testing or diagnostic imaging are appropriate subjects, or evaluations of recent innovations
Case Reports – Learning from Tragedy – Case reports of diagnostic error or dilemma discussed from a multi-stakeholder perspective; should include the facts of the case, a discussion focused on a root cause analysis, take-away points or action items resulting from the analysis, and whenever possible input from both the affected patients and their providers
Case Reports – Lessons in Clinical Reasoning: Pitfalls, Myths, and Pearls – Case reports in which a clinician discusses their diagnostic approach after clinical information is presented, focusing on a case in which a diagnostic error (or near miss = great catch) occurred
Patient-Focused Articles – Papers in this category should be written in lay language on a topic of interest to the patient stakeholder community
Diagnosis in the News – Brief reports of news-worthy advances in diagnosis, or problems involving diagnostic error

Volume 1 Issue 2

Issue of Diagnosis

Frontmatter

A missed opportunity – a near disaster

Diagnostic error in community-acquired pneumonia

A missed opportunity—a near disaster

Abstract

Defensive medicine and diagnostic testing

Abstract

Missed diagnosis of stroke in the emergency department: a cross-sectional analysis of a large population-based sample

Abstract

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

Abstract

Failure mode effects and criticality analysis: innovative risk assessment to identify critical areas for improvement in emergency department sepsis resuscitation

Abstract

Path dependence and routines: a threat to capability development

Abstract

Diagnostic conversations: Clinical Decision Making in surgery – Part 2

Abstract

Analytical assessment of the Beckman Coulter Unicel DxI AccuTnI+3 immunoassay