Types and origins of diagnostic errors in primary care settings

JAMA Internal Medicine

Volumn 173, Issue 6, 2013, Pages 418-425

  Singh, Hardeep ^a   Giardina, Traber Davis ^a   Meyer, Ashley N D ^a   Forjuoh, Samuel N ^b   Reis, Michael D ^b   Thomas, Eric J ^c  

^a BAYLOR COLLEGE OF MEDICINE   (United States)

^b TEXAS A AND M HEALTH SCIENCE CENTER   (United States)

^c UNIVERSITY OF TEXAS MEDICAL SCHOOL   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ABSCESS; ACUTE CORONARY SYNDROME; ACUTE KIDNEY FAILURE; ADULT; AGED; ANEMIA; ANGINA PECTORIS; ARTERY OCCLUSION; ARTICLE; BACTEREMIA; CONGESTIVE HEART FAILURE; DEEP VEIN THROMBOSIS; DIAGNOSTIC ERROR; DIAGNOSTIC TEST; ELECTROLYTE DISTURBANCE; ELECTRONIC MEDICAL RECORD; FEMALE; FOLLOW UP; HEALTH CARE SYSTEM; HEART ARRHYTHMIA; HUMAN; HYPERGLYCEMIA; LUNG EMBOLISM; MAJOR CLINICAL STUDY; MALE; NEOPLASM; NEPHROLITHIASIS; OSTEOMYELITIS; PATIENT SAFETY; PERIPHERAL VASCULAR DISEASE; PNEUMONIA; PORTAL HYPERTENSION; PRIMARY MEDICAL CARE; PRIORITY JOURNAL; PYELONEPHRITIS; SPINAL CORD COMPRESSION; SYMPTOM; URINARY TRACT INFECTION;

AGED; AMBULATORY CARE; AMBULATORY CARE INFORMATION SYSTEMS; DIAGNOSIS; DIAGNOSTIC ERRORS; DISEASE; ELECTRONIC HEALTH RECORDS; FEMALE; HEALTH CARE SURVEYS; HUMANS; MALE; MIDDLE AGED; OUTCOME ASSESSMENT (HEALTH CARE); PRIMARY HEALTH CARE; QUALITY OF HEALTH CARE; UNITED STATES; UNITED STATES DEPARTMENT OF VETERANS AFFAIRS;

EID: 84875761262     PISSN: 21686106     EISSN: None     Source Type: Journal    
DOI: 10.1001/jamainternmed.2013.2777     Document Type: Article

References (38)

1. Bhasale A. The wrong diagnosis: identifying causes of potentially adverse events in general practice using incident monitoring. Fam Pract. 1998;15(4):308-318.
2. Bhasale AL, Miller GC, Reid SE, Britt HC. Analysing potential harm in Australian general practice: an incident-monitoring study. Med J Aust. 1998;169(2): 73-76.
3. Dovey SM, Meyers DS, Phillips RL Jr, et al. A preliminary taxonomy of medical errors in family practice. Qual Saf Health Care. 2002;11(3):233-238.
4. Dovey SM, Phillips RL, Green LA, Fryer GE. Consequences of medical errors observed by family physicians. Am Fam Physician. 2003;67(5):915.
5. Elder NC, Dovey SM. Classification of medical errors and preventable adverse events in primary care: a synthesis of the literature. J Fam Pract. 2002;51(11): 927-932.
6. Ely JW, Levinson W, Elder NC, Mainous AG III, Vinson DC. Perceived causes of family physicians' errors. J Fam Pract. 1995;40(4):337-344.
7. Graber ML, Franklin N, Gordon R. Diagnostic error in internal medicine. Arch Intern Med. 2005;165(13):1493-1499.
8. Bishop TF, Ryan AM, Casalino LP. Paid malpractice claims for adverse events in inpatient and outpatient settings. JAMA. 2011;305(23):2427-2431.
9. Gandhi TK. Fumbled handoffs: one dropped ball after another. Ann Intern Med. 2005;142(5):352-358.
10. Gandhi TK, Kachalia A, Thomas EJ, et al. Missed and delayed diagnoses in the ambulatory setting: a study of closed malpractice claims. Ann Intern Med. 2006; 145(7):488-496.
11. Phillips RL Jr, Bartholomew LA, Dovey SM, Fryer GE Jr, Miyoshi TJ, Green LA. Learning frommalpractice claims about negligent, adverse events in primary care in the United States. Qual Saf Health Care. 2004;13(2):121-126.
12. Sandars J, Esmail A. The frequency and nature of medical error in primary care: understanding the diversity across studies. Fam Pract. 2003;20(3):231-236.
13. Singh H, Weingart SN. Diagnostic errors in ambulatory care: dimensions and preventive strategies. Adv Health Sci Educ Theory Pract. 2009;14(suppl 1): 57-61.
14. Singh H, Graber M. Reducing diagnostic error through medical home-based primary care reform. JAMA. 2010;304(4):463-464.
15. Schiff GD, Hasan O, Kim S, et al. Diagnostic error in medicine: analysis of 583 physician-reported errors. Arch Intern Med. 2009;169(20):1881-1887.
16. Ely JW, Kaldjian LC, D'Alessandro DM. Diagnostic errors in primary care: lessons learned. J Am Board Fam Med. 2012;25(1):87-97.
17. Sarkar U, Bonacum D, Strull W, et al. Challenges of making a diagnosis in the outpatient setting: a multi-site survey of primary care physicians. BMJ Qual Saf. 2012;21(8):641-648.
18. Lorincz CY, Drazen E, Sokol PE, et al. Research in Ambulatory Patient Safety 2000-2010: A 10-Year Review. Chicago, IL: American Medical Association; 2011.
19. Wynia MK, Classen DC. Improving ambulatory patient safety: learning from the last decade, moving ahead in the next. JAMA. 2011;306(22):2504-2505.
20. Singh H, Giardina TD, Forjuoh SN, et al. Electronic health record-based surveillance of diagnostic errors in primary care. BMJ Qual Saf. 2012;21(2):93-100.
21. Singh H, Daci K, Petersen LA, et al. Missed opportunities to initiate endoscopic evaluation for colorectal cancer diagnosis. Am J Gastroenterol. 2009;104(10): 2543-2554.
22. Singh H, Hirani K, Kadiyala H, et al. Characteristics and predictors of missed opportunities in lung cancer diagnosis: an electronic health record-based study. J Clin Oncol. 2010;28(20):3307-3315.
23. Singh H, Davis GT, Petersen LA, et al. Exploring situational awareness in diagnostic errors in primary care. BMJ Qual Saf. 2011;21(1):30-38.
24. Schiff GD, Kim S, Abrams R, Cosby K, Lambert B, Elstein AS; Agency for Healthcare Research and Quality. Diagnosing diagnosis errors: lessons from a multi-institutional collaborative project. In: Henriksen K, Battles JB, Marks ES, Lewin DI, eds. Advances in Patient Safety: From Research to Implementation: Volume 2: Concepts and Methodology. Rockville, MD: Agency for Healthcare Research and Quality; 2005:255-278.
25. Singh H, Thomas EJ, Wilson L, et al. Errors of diagnosis in pediatric practice: a multisite survey. Pediatrics. 2010;126(1):70-79.
26. Singh H, Thomas EJ, Khan MM, Petersen LA. Identifying diagnostic errors in primary care using an electronic screening algorithm. Arch Intern Med. 2007; 167(3):302-308.
27. Singh H, Sethi S, Raber M, Petersen LA. Errors in cancer diagnosis: current understanding and future directions. J Clin Oncol. 2007;25(31):5009- 5018.
28. Singh H, Graber ML, Kissam SM, et al. System-related interventions to reduce diagnostic errors: a narrative review. BMJ Qual Saf. 2012;21(2):160-170.
29. Singh H, Mani S, Espadas D, Petersen N, Franklin V, Petersen LA. Prescription errors and outcomes related to inconsistent information transmitted through computerized order entry: a prospective study. Arch Intern Med. 2009;169(10): 982-989.
30. Kostopoulou O, Delaney BC, Munro CW. Diagnostic difficulty and error in primary care: a systematic review. Fam Pract. 2008;25(6):400-413.
31. Sittig DF, Singh H. Electronic health records and national patient-safety goals. N Engl J Med. 2012;367(19):1854-1860.
32. Zwaan L, de Bruijne M, Wagner C, et al. Patient record review of the incidence, consequences, and causes of diagnostic adverse events. Arch Intern Med. 2010; 170(12):1015-1021.
33. Paley L, Zornitzki T, Cohen J, Friedman J, Kozak N, Schattner A. Utility of clinical examination in the diagnosis of emergency department patients admitted to the department of medicine of an academic hospital. Arch Intern Med. 2011;171 (15):1394-1396.
34. Schiff GD, Bates DW. Can electronic clinical documentation help prevent diagnostic errors? N Engl J Med. 2010;362(12):1066-1069.
35. Ely JW, Graber ML, Croskerry P. Checklists to reduce diagnostic errors. Acad Med. 2011;86(3):307-313.
36. Graber ML, Kissam S, Payne VL, et al. Cognitive interventions to reduce diagnostic error: a narrative review. BMJ Qual Saf. 2012;21(7):535-557.
37. Trowbridge R, Salvador D. Addressing Diagnostic Errors: An Institutional Approach. Boston, MA: The National Patient Safety Foundation; 2010;13:1-2. http://www.npsf.org/wp-content/uploads/2011/09/Focus-13.3-2010.pdf. Accessed January 7, 2012.
38. Zwaan L, Thijs A, Wagner C, van der Wal G, Timmermans DR. Relating faults in diagnostic reasoning with diagnostic errors and patient harm. Acad Med. 2012; 87(2):149-156.