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Showing results for tags 'Diagnostic error'.
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News Article
‘I developed ovarian cancer after my symptoms were dismissed as menopause’
Patient Safety Learning posted a news article in News
A woman has said her ovarian cancer diagnosis was delayed after her symptoms were wrongly dismissed as menopause or irritable bowel syndrome (IBS) – accusing her doctor of misogyny and medically gaslighting her. Sbba Siddique, a 55-year-old business owner, told The Independent that “unconscious bias and cultural incompetence” were also to blame for her delayed diagnosis. Ms Siddique, who lives in Berkshire, said she began to feel unwell around October 2021 but did not get diagnosed with late-stage ovarian cancer until March the following year. “I was feeling really tired all the time. I had no energy. I was piling on weight that wasn’t there previously despite not changing my eating habits. I was needing to wee more,” the mother of three recalled. “I was going back and forth with my GP trying to get an appointment. I couldn’t get a face-to-face – every consultation was on the phone or via online forms. That was part of the problem of the misdiagnosis.” Her GP was “very dismissive” of her symptoms and attributed them to IBS or the menopause, she added. “At the end of the day, I’m not the expert, the GP is – I believed him,” she said. Read full story Source: The Independent, 14 July 2024 -
Content ArticleIn this blog, consultant rheumatologist and RCP Digital Health Clinical Lead Anne Kinderlerer looks at how digital solutions could improve patient care and safety in outpatients. She highlights that existing triage systems make it difficult to manage risk across pathways and outlines how digital tools might enable patients to access the right support at the time when they most need it. She also describes why increasing interoperability and sharing of data between primary and secondary care will be vital to improving how the health service predicts and manages risk, reducing health inequalities and preventing patients getting 'lost in the system'.
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Content Article
Clinical Communiqué (June 2024)
Anonymous posted an article in Patient stories
The Communiqués are an Australian not-for-profit group that develop, produce and distribute innovative and free electronic educational publications and podcasts on lessons learned from Coroners’ investigations into preventable healthcare-related deaths. -
News Article'PAs' - who have just two years training - are being used to treat NHS patients, but doctors are concerned about patient safety, reports Sarah Graham. PAs, or physician associates, are a relatively new type of health professional, first introduced in the UK in 2003 and increasingly used across the NHS to provide care to patients, including at GP surgeries. They undergo two years of postgraduate training (compared with the ten years of medical training needed to become a GP). There are now more than 3,000 PAs working in the NHS. The Government has said it wants to increase the number to 10,000 by 2037, but the scheme has become controversial following a series of reports of patients being misdiagnosed, some with fatal consequences. As far as Dave Hay knew, he was seeing a GP. It was 2022 and he’d started having bouts of dizziness, brain fog and fatigue. “It was having an impact on my work and everyday life, so I called my local surgery to make an appointment. I saw someone who wasn’t my usual doctor, but she introduced herself as Dr Smith,” says Hay, 57, a scientist from Yorkshire. “I explained my symptoms. She didn’t do any kind of examination – didn’t check my ears or my vision – and just said, ‘look, I don’t think there’s anything seriously wrong with you, but come back if your symptoms get worse’,” he says. Two weeks later Dave, now 57, a scientist from Yorkshire, felt worse. It was only later, during a chance conversation with the practice nurse, that Dave learned he hadn’t been seeing a GP at all. “I was at a routine appointment and explained what had happened,” Dave says. “The nurse asked who I’d seen and said, ‘that’s not a doctor, that’s a PA’. I had no idea what a PA was.” When Dave arranged an appointment with one of the named GPs, she diagnosed depression and anxiety, because of issues at work and a recent family bereavement. “She looked at my medical history and asked some much more targeted questions, pieced it all together, and recommended talking therapy and antidepressants,” Dave explains, who is now well. However, he does feel that he was misled and waited longer for the right treatment because the PA did not explain her actual role, which they are supposed to do. Read full story Source: iNews, 1 Jul7 2024
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Content ArticleDiagnostic error is largely discovered and evaluated through self-reporting and manual review, which is costly and not suitable for real-time intervention. AI presents new opportunities to use electronic health record data for automated detection of potential misdiagnosis, executed at scale and generalised across diseases. The authors of this study propose a new, automated approach to identifying diagnostic divergence considering both diagnosis and risk of mortality. The aim of this study was to identify cases of misdiagnosis of infectious disease in the emergency department by measuring the difference between predicted diagnosis and documented diagnosis, weighted by mortality. Two machine learning models were trained for prediction of infectious disease and mortality using the first 24 hours of data. Charts were manually reviewed by clinicians to determine whether there could have been a more correct or timely diagnosis.
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Content ArticleAlthough diagnostic errors are estimated to affect about 12 million Americans each year in ambulatory care settings alone, the conceptual and pragmatic scientific foundations for their measurement are under-developed. Further progress towards reducing diagnostic errors will rely on our ability to overcome measurement-related challenges. This article in BMJ Quality & Safety outlines a multifaceted framework to advance the science of measuring diagnostic errors (The Safer Dx framework). The authors describe how Safer DX serves as a conceptual foundation for system-wide safety measurement, monitoring and improvement of diagnostic error. They believe it lays robust groundwork for measurement and monitoring techniques to ensure diagnostic safety.
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EventuntilJoin Patients for Patient Safety US for 3 days of events centred around World Patient Safety Day (WPSD) 2024. PFPS US urges Americans impacted by missed or delayed diagnoses, bias or medical error to convene in Washington, DC for a Summit held September 15-17, 2024. The World Health Organization designates 17 September 17 as World Patient Safety Day, and WPSD 2024’s theme is Improving Diagnosis for Patient Safety. Find the full Summit event list at https://www.pfps.us/wpsd-2024, including: Sunday 15 September: Welcome reception and dinner at Johns Hopkins University Bloomberg Center to launch Project PIVOT, a national project identifying patient-prioritized outcomes and experiences and collaboration with patient organizations, US Department of Health and Human Services, Johns Hopkins University, Harvard Medical School and others. Monday 16 September: Participants visit Capitol Hill to urge Congressional leaders to ACT Now for patient safety, diagnostic safety and health equity solutions. ACT Now is PFPS US’s urgent request to leaders for Accountability, Coordination, and Transparency in health care. Later, PFPS US and AcademyHealth co-host a film premiere of The Pitch: The Next Generation of Patient Safety. From immersive tech to AI machine learning, innovations are finally making waves in medicine with the goal of safer health care. The Pitch gives a unique look at the American health care system’s ongoing challenge to embrace the next generation of patient safety. Tuesday 17 September, World Patient Safety Day: The March for Patient Safety begins at Freedom Plaza and ends with a ceremony on the US Capitol Lawn, where marchers will remember those whose lives have been lost to or impacted by preventable harm. Afterwards, PFPS US and the Bloomberg Center co-host a World Patient Safety Day Leadership Briefing with government leaders. Further information and to sign up
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News Article
Mother faces terminal cancer after years of misdiagnosis by the NHS
Patient Safety Learning posted a news article in News
A woman is battling a terminal cervical cancer diagnosis after an NHS trust misdiagnosed her test results as constipation several times. Sarah Roch, a 43-year-old mother of two from Plymouth, faced nine years of missed opportunities from 2010 by Derriford Hospital and only discovered she had cervical cancer after a voluntary hysterectomy in 2019. By the time she was diagnosed - which occurred by accident following her hysterectomy - Ms Roch was told she had late-stage cervical cancer. Ms Roch, who worked at the same hospital which misdiagnosed her, has had to give up her job to have chemotherapy three times a week. She is now calling for greater awareness of cervical cancer symptoms and has urged women to seek a second opinion if they feel something isn’t right. Read full story Source: The Independent, 17 June 2024 -
Community PostHave you or someone you know been affected by a: delayed diagnosis incorrect diagnosis missed diagnosis? Errors can happen at every stage of the diagnostic process and can happen in all healthcare settings. In some circumstances the impact is life-changing. If you have insights to share around diagnostic error and the impact on patient safety, please comment below (sign up first here, for free). Or you can contact us directly at content@pslhub.org.
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Content ArticleThis report commissioned by the US Agency for Healthcare Research and Quality aims to identify major themes related to the current state of diagnostic safety and highlight key gaps in knowledge. Through a rapid narrative review methodology to evaluate multiple resources in the literature and interviews with experts, it presents several findings that have implications for future resource investments to reduce harm from diagnostic errors. The report looks at the following key themes: Incidence and Contributing Factors Measurement: Data and Methods Cognitive Processes Culture, Workflow, and Work System Issues Disparities Health Information Technology Patients and Families Testing Interventions Implementation
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Content ArticleDespite growing awareness of diagnostic error, most healthcare systems do not track or record diagnostic quality, and many diagnostic safety events are not recognised. Without methods to identify, measure, investigate and analyse events, healthcare organisations cannot understand causes of diagnostic errors, identify contributing factors or create solutions. One of the best ways to collect information about diagnostic errors is through self-reporting by patients and healthcare professionals. This issue brief from the Agency for Healthcare Research and Quality looks at how to foster psychological safety and organisational safety culture in order to reduce harm from diagnostic error.
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Content ArticleKerri Mothersole was a 44 year old woman who had a past medical history of asthma, labyrinthitis, depression and back pain. In May 2020 she was seen with symptoms of possible early menopause and blood tests requested. In October 2020 she was noted to be suffering from tiredness and had irregular periods and again blood tests were requested. Blood tests taken in January 2021 noted a low haemoglobin and ferritin so iron was prescribed as well as follow up in two months. In March 2021 she complained of having per vaginal bleeding for six weeks and she was referred for an ultrasound. Due to her underlying ill health, she had difficulty in attending appointments and missed a number of different appointments. She was seen in the surgery on 21 June 2021 by her General Practitioner who noted abdominal tenderness and weight loss and he again referred her for an ultrasound. An ultrasound was undertaken by a private firm HEM Clinical Ultrasound on 28 June 2021 but the report was never sent to her General Practitioner. A second ultrasound on the 1 July 2021suggested a diagnosis of adenomyosis but noting that serious pathology could not be ruled out. Only the second report was sent to the General Practitioner which led to a routine gynaecology referral, she had however already been referred to the colorectal team on the urgent two week wait pathway. Had the earlier scan report been seen this would have led to an urgent referral to gynaecology. There were a number of missed appointments and a colonoscopy took place on 20 October 2021. The procedure was negative but the endoscopist thought he could feel something in the pelvis and a CT scan was arranged. The CT scan on 28 October 2021 demonstrated a large pelvic mass and she was referred to the gynaecology team in early December and a multidisciplinary team meeting discussion on 17 December 2021 led to a request for an MRI scan. Appointments were made for 31 December 2021, 25 January 2022 and again in February but not attended and she eventually underwent an MRI on 1 May 2022 which revealed a large mass. She was again discussed at the multidisciplinary team meeting on 6 May 2022 and referred to the gynae-oncology surgeons at Maidstone hospital. She was seen on 1 June 2022 and booked for surgery on 27 June 2022. She was, however, far too unwell for surgery on 27 June 2022 and further investigations revealed brain metastases. She was admitted to hospital and treated with steroids and referred to the Oncologists as surgery was deemed no longer appropriate. She was prescribed hormone treatment but she was, by now, too unwell to receive even palliative radiotherapy. She was taken to Medway Maritime hospital on 19 August 2022 and was struggling as she had been so unwell at home. Whilst plans were being made to provide some care at home she remained overnight but sadly died on 20 August 2022 as she was so unwell she could not return home.
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Content Article
Diagnostic error in mental health: a review (4 April 2024)
Mark Hughes posted an article in Diagnostic error
Diagnostic errors are associated with patient harm and suboptimal outcomes. However, despite efforts to advance definition, measurement and interventions for diagnostic error, diagnosis in mental health is not well represented in this ongoing work. The authors of this article, published in BMJ Safety & Quality, summarise the current state of research on diagnostic errors in mental health and identify opportunities to align future research with the emerging science of diagnostic safety. -
News Article
Hospitals grapple with radiologist shortage
Patient-Safety-Learning posted a news article in News
Increased reliance on imaging for diagnosis and efficient patient care mixed with higher volumes of patients has left US hospitals scrambling to meet demand with the few radiologists they have. There are over 1,400 vacant radiologist positions posted on the American College of Radiology's job board, according to a bulletin posted on its website. The total number of active radiology and diagnostic radiology physicians has dropped by 1% between 2007 and 2021, but the number of people in the U.S. per active physician in radiology grew nearly 10%, according to the Association of American Medical Colleges. An increase in the Medicare population and a declining number of people with health insurance adds to the problem. "Demand for imaging services is increasing across the country, creating longer worklists for radiology staff at the same time the healthcare system is experiencing a workforce shortage in radiology," Michigan Hospital Association CEO Brian Peters told The Detroit News in an April 28 report. "The combination of vacancies and increased demand can force imaging delays measured from days to upwards of two weeks." CMS also cut fees for both diagnostic (3%) and interventional radiology (4%) this year, according to an article published on healthcare technology company XiFin's website. This leaves many hospitals having to use external groups to stay on top of demand. Mr. Peters told Detroit News, "Hospitals and health systems are also competing with practices offering remote-only positions, which allows Michigan radiologists to work for out-of-state providers at higher rates." Read full story Source: Becker's Hospital Review, 29 April 2024 -
Content ArticleThis article tells the story of 61 year-old Susannah Constantine who was diagnosed with a rare neurological condition after her MRI was not looked at by her GP surgery for over a year. Susannah decided to have a private MRI when doctors couldn't diagnose why she’d been suffering from tinnitus and pins and needles in the fingers of her left hand. The results were sent to her GP, and Susannah heard no more, so struggled on for another year—she gradually became weaker and her muscles atrophied. She called her GP surgery to check if the MRI held any clues and learnt no one there had ever looked at the results—they had just been sat there for a year. She was told she needed to see a neurosurgeon immediately and was diagnosed with arteriovenous malformation (AVM), a rare neurological condition that disrupts the flow of blood and oxygen to the brain. If not spotted and treated in good time there is a one in three chance of suffering a brain haemorrhage, paralysis or stroke.
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Content Article
Improving diagnosis in health care (2015)
Patient-Safety-Learning posted an article in Diagnosis
This report is a continuation of the landmark Institute of Medicine reports To Err Is Human (2000) and Crossing the Quality Chasm (2001). It finds that diagnosis, and in particular the occurrence of diagnostic errors, has been largely unappreciated in efforts to improve the quality and safety of healthcare. Without a dedicated focus on improving diagnosis, diagnostic errors will likely worsen as the delivery of health care and the diagnostic process continue to increase in complexity. Just as the diagnostic process is a collaborative activity, improving diagnosis will require collaboration and a widespread commitment to change among health care professionals, healthcare organisations, patients and their families, researchers and policy makers. The report's recommendations contribute to the growing momentum for change in this crucial area of healthcare quality and safety. -
Content ArticleThe use of checklists as a tool to improve performance has proven successful in a variety of healthcare settings. For instance, checklists have been successful in preventing hospital-acquired infections and preventing errors in the surgical process. The use of checklists has also been recommended as a tool to reduce diagnostic errors. Diagnostic errors are frequent and often have severe consequences but have received little attention in the field of patient safety. Checklists are considered a promising intervention for the area of diagnosis because they can support clinicians in their diagnostic decision making by helping them take correct diagnostic steps and ensuring that possible diagnoses are not overlooked. This Agency for Health Research and Quality (AHRQ) issue brief summarises current evidence on using checklists to improve diagnostic reasoning.
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Content ArticleDiagnostic errors cause substantial preventable harms worldwide, but rigorous estimates for total burden are lacking. Newman-Toker and colleague previously estimated diagnostic error and serious harm rates for key dangerous diseases in major disease categories and validated plausible ranges using clinical experts. In this study they estimated the annual US burden of serious misdiagnosis-related harms (permanent morbidity, mortality) by combining prior results with rigorous estimates of disease incidence. They found that an estimated 795 000 Americans become permanently disabled or die annually across care settings because dangerous diseases are misdiagnosed. Just 15 diseases account for about half of all serious harms, so the problem may be more tractable than previously imagined.
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Content ArticleThis research letter in JAMA Internal Medicine describes a multicentre retrospective cohort study that investigated associations between stigmatising language, errors in the diagnostic process and demographics for hospitalised patients. The study found that stigmatising language in patient documentation was associated with diagnostic error and multiple diagnostic process errors. The prevalence of stigmatising language was higher in documentation relating to Black patients and patients with housing instability. The authors argue that this may be indicative of clinician biases that interfere with data gathering, communication and clinical reasoning. They call for further research to explore the mechanisms behind this and to understand how clinician use of stigmatising language can be reduced.
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Content ArticleThe US Leapfrog Group has released Recognizing excellence in diagnosis: Leapfrog’s national pilot survey report, which analyses responses from 95 hospitals on their implementation of recommended practices to address diagnostic errors, defined as delayed, wrong or missed diagnoses or diagnoses not effectively communicated to the patient or family. The National Academy of Medicine has warned that virtually every American will suffer the consequences of a diagnostic error at least once in their lifetime and noted that 250,000 hospital inpatients will experience a diagnostic error every year. While progress varies considerably, more than 60% of hospitals responded that they were either already implementing or preparing to implement each of 29 evidence-based practices known to prevent harm from diagnostic error. The practices were identified in an earlier Leapfrog report, Recognizing excellence in diagnosis: Recommended practices for hospitals. The hospitals reported barriers to putting the practices in place that include staffing shortages and budgetary pressure.
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Content Article
World Patient Safety Day 2024
Patient Safety Learning posted an article in WHO
This year’s World Patient Safety Day (WPSD) on 17 September 2024 is focused on the theme “Improving diagnosis for patient safety”. This article explains the aims of the event and the areas it will cover. -
Content ArticleThis qualitative study in the Journal of Patient Safety aimed to understand the perception of dental patients who have experienced a dental diagnostic error and to identify patient-centred strategies to help reduce future occurrences. Recruiting patients via social media, the researchers conducted a screening survey, initial assessment and 67 individual patient interviews to capture the effects of misdiagnosis, missed diagnosis or delayed diagnosis on patient lives. They found that dental patients endured prolonged suffering, disease progression, unnecessary treatments and the development of new symptoms as a result of diagnostic errors. Patients believed that the following factors contributed to diagnostic errors: Poor provider communication Inadequate time with provider Lack of patient self-advocacy and health literacy. Patients suggested that future diagnostic errors could be mitigated through: improvements in provider chairside manners more detailed patient diagnostic workups improving personal self-advocacy enhanced reporting systems.
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Content ArticleThis cohort study in JAMA Network explored the incidence of and factors associated with inappropriate diagnosis of pneumonia in hospitalised patients. The results showed that older patients, those with dementia and those presenting with altered mental status had the highest risk of being inappropriately diagnosed. For those who were inappropriately diagnosed, full antibiotic duration was associated with antibiotic-associated adverse events.
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Content ArticleIn this episode, we hear from Sue Allison who blew the whistle on a Senior Radiologist within her department who repeatedly failed to diagnose women who had breast cancer at NHS Morecambe Bay Trust. She explains her battle to overturn her NDA at employment tribunal and the ‘insidious bullying’ that followed after blowing the whistle on concerns about patient safety. She is joined by Samantha Prosser an experienced employment law litigator from BDBF LLP who has specialist experience in advising private and NHS consultants from leading hospitals on private and NHS whistleblowing and discrimination claims.
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Content ArticleDiagnostic errors cause significant patient harm. The clinician’s ultimate goal is to achieve diagnostic excellence in order to serve patients safely. This can be accomplished by learning from both errors and successes in patient care. However, the extent to which clinicians grow and navigate diagnostic errors and successes in patient care is poorly understood. Clinically experienced hospitalists, who have cared for numerous acutely ill patients, should have great insights from their successes and mistakes to inform others striving for excellence in patient care.
