The challenges in defining and measuring diagnostic error

Diagnosis

Volumn 2, Issue 2, 2015, Pages 97-103

  Zwaan, Laura ^a,b   Singh, Hardeep ^c  

^a ERASMUS MEDICAL CENTER   (Netherlands)

^b VU UNIVERSITY MEDICAL CENTER   (Netherlands)

^c BAYLOR COLLEGE OF MEDICINE   (United States)

Author keywords

clinical decision making; cognitive errors; diagnostic error; judgment; patient safety

Indexed keywords

ARTICLE; CLINICAL FEATURE; CLINICAL RESEARCH; DIAGNOSIS; DIAGNOSTIC ERROR; DIAGNOSTIC REASONING; DIAGNOSTIC TEST; DIFFERENTIAL DIAGNOSIS; DISEASE ASSOCIATION; DISEASE SEVERITY; GOOD CLINICAL PRACTICE; HEALTH CARE; HEALTH CARE SYSTEM; HINDSIGHT BIAS; HUMAN; MEDICAL ERROR; MEDICAL INFORMATION; OUTCOME ASSESSMENT; OUTPATIENT CARE; OVERDIAGNOSIS; PATIENT SAFETY; PRIORITY JOURNAL; TRIANGULATION; UNDERDIAGNOSIS;

EID: 85117624322     PISSN: 21948011     EISSN: 2194802X     Source Type: Journal    
DOI: 10.1515/dx-2014-0069     Document Type: Article

References (41)

1. Berner ES, Graber ML. Overconfidence as a cause of diagnostic error in medicine. Am J Med. 2008;121(Suppl 5):S2-23.
2. Zwaan L, De Bruijne MC, Wagner C, Thijs A, Smits M, Van der Wal G, et al. Patient record review on the incidence, consequences and causes of diagnostic adverse events. Arch Intern Med. 2010;170:1015-21.
3. Zwaan L, Thijs A, Wagner C, Van der Wal G, Timmermans D. Relating faults in diagnostic reasoning with diagnostic errors and patient harm. Acad Med. 2012;87:149-56.
4. Newman-Toker D, Pronovost P. Diagnostic errors-the next frontier for patient safety. J Am Med Assoc. 2009;301:1062-2.
5. Graber M, Plebani M. Diagnosis: A new era, a new journal. Diagnosis. 2014;1:1-2.
6. Singh H. Diagnostic errors: Moving beyond'no respect' and getting ready for prime time. BMJ Qual Saf. 2013;22:789-92.
7. Wachter R. Why diagnostic errors don't get any respect-and what can be done about them. Health Aff(Millwood). 2010;29:1605-10.
8. Schiff G, Puopolo A, Huben-Kearney A, Yu W, Keohane C, McDonough P, et al. Primary care closed claims experience of Massachusetts malpractice insurers. JAMA Intern Med. 2013;173:2063-8.
9. Saber Tehrani A, Lee H, Mathews S, Shore A, Makary M, Pronovost P, et al. 25-Year summary of US malpractice claims for diagnostic errors 1986-2010: An analysis from the National Practitioner Data Bank. BMJ Qual Saf. 2013;22:672-80.
10. Zwaan L, Schiff G, Singh H. Advancing the research agenda for diagnostic error reduction. BMJ Qual Saf. 2013;22:ii52-ii7.
11. Singh H, Meyer A, Thomas E. The frequency of diagnostic errors in outpatient care: Estimations from three large observational studies involving US adult populations. Brit Med J Qual Saf. 2014;23:727-31.
12. Graber ML, Franklin N, Gordon R. Diagnostic error in internal medicine. Arch Intern Med. 2005;165:1493-9.
13. Singh H. Helping health care organizations to define diagnostic errors as missed opportunities in diagnosis. Jt Comm J Qual Saf. 2014;40:99-101.
14. Schiff GD, Hasan O, Kim S, Abrams R, Cosby K, Lambert BL, et al. Diagnostic Error in Medicine: Analysis of 583 Physician-Reported Errors. Arch Intern Med. 2009;169:1881-7.
15. Newman-Toker D. A unified conceptual model for diagnostic errors: Underdiagnosis, overdiagnosis, and misdiagnosis. Diagnosis. 2014;1:43-8.
16. Arkes H, Wortmann R, Saville P, Harkness A. Hindsight bias among physicians weighing the likelihood of diagnoses. J Appl Psychol. 1981;66:252-4.
17. Henriksen K, Kaplan H. Hindsight bias, outcome knowledge and adaptive learning. Qual Saf Health Care. 2003;12:ii46-ii50.
18. Edelman D. Outpatient diagnostic errors: Unrecognized hyperglycemia. Eff Clin Pract. 2002;5:11-6.
19. Chow CK, Teo KK, Rangarajan S, Islam S, Gupta R, Avezum A, et al. Prevalence, awareness, treatment, and control of hypertension in rural and urban communities in high-, middle-, and low-income countries. J Am Med Assoc. 2013;310:959-68.
20. Welch G, Schwartz L, Woloshin S. Overdiagnosed: Making people sick in pursuit of health. Boston, Massachusetts: Beacon Press; 2011.
21. Burroughs TE, Waterman AD, Gallagher TH, Waterman B, Adams D, Jeffe DB, et al. Patient concerns about medical errors in emergency departments. Acad Emerg Med. 2005;12:57-64.
22. Hofmann B. Diagnosing overdiagnosis: Conceptual challenges and suggested solutions. Eur J Epidemiol. 2014;29:599-604.
23. Moynihan R, Doust J, Henry D. Preventing overdiagnosis: How to stop harming the healthy. Brit Med J. 2012;344:e3502.
24. Jørgensen K, Gøtzsche P. Overdiagnosis in publicly organised mammography screening programmes: Systematic review of incidence trends.Brit Med J. 2009;339(b2587
25. Welch G, Black W. Overdiagnosis in cancer. J Natl Cancer Inst. 2010;102:605-13.
26. Wiener R, Schwartz L, Woloshin S. Time trends in pulmonary embolism in the United States: Evidence of overdiagnosis. Arch Intern Med. 2011;171:831-7.
27. Graber M, Kumar A. Commentary: Reaching a milestone in diagnosing coeliac disease. Brit Med J. 2007;334:732.
28. Gasbarrini G, Miele L, Malandrino N, Grieco A, Addolorato G, Gasbarrini A, et al. Celiac disease in the 21st century: Issues of under-and over-diagnosis. Int J Immunopathol Pharmacol 2009;22:1-7.
29. Hamilton W, Lancashire R, Sharp D, Peters T, Cheng K, Marshall T. The risk of colorectal cancer with symptoms at different ages and between the sexes: A case-control study. BMC Med. 2009;7.
30. Wears R, Nemeth C. Replacing hindsight with insight: Toward better understanding of diagnostic failures. Ann Emerg Med. 2007;49:206-9.
31. Wears R. What makes diagnosis hard? Adv in Health Sci Educ. 2009;14:19-25.
32. Singh H, Sittig D. Advancing the science of measurement of diagnostic errors in healthcare: The Safer Dx framework. BMJ Qual Saf. 2015;24:103-10.
33. Singh H, Giardina T, Meyer A, Forjuoh S, Reis M, Thomas E. Types and Origins of Diagnostic Errors in Primary Care Settings. JAMA Intern Med. 2013;173:418-25.
34. Singh H, Hirani K, Kadiyala H, Rudomiotov O, Davis T, Khan MM, et al. Characteristics and predictors of missed opportunities in lung cancer diagnosis: An electronic health record-based study. J Clin Oncol. 2010;28:3307-15.
35. Brennan T, Leape L, Laird N, Hebert L, Localio A, Lawthers A, et al. Incidence of Adverse Events and Negligence in Hospitalized Patients. New Engl J Med. 1991;324:370-6.
36. Baker GR, Norton PG, Flintoft V, Blais R, Brown A, Cox J, et al. The Canadian Adverse Events Study: The incidence of adverse events among hospital patients in Canada. Can Med Assoc J. 2004;170:1678-86.
37. Zegers M, De Bruijne MC, Wagner C, Hoonhout LH, Waaijman R, Smits M, et al. Adverse events and potentially preventable deaths in Dutch hospitals: Results of a retrospective patient record review study. Qual Saf Health Care. 2009;18:297-302.
38. Forster A, O'Rourke K, Shojania K, Van Walraven C. Combining ratings from multiple physician reviewers helped to overcome the uncertainty associated with adverse event classification. J Clin Epidemiol. 2007;60:892-901.
39. Zegers M, De Bruijne M, Wagner C, Groenewegen P, Van der Wal G, De Vet H. The inter-rater agreement of retrospective assessments of adverse events does not improve with two reviewers per patient record. J Clin Epid. 2010 2010;63:94-102.
40. Shojania K. The elephant of patient safety: What you see depends on how you look. Jt Comm J Qual Saf. 2010;36: 399-401.
41. Christiaans-Dingelhoff I, Smits M, Zwaan L, Lubberding S, Van der Wal G, Wagner C. To what extent are adverse events found in patient records reported by patients and healthcare professionals via complaints, claims and incident reports? BMC Health Serv Res. 2011;11:49.