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Diagnostic errors are a known patient safety concern across all clinical settings, including the emergency department (ED). We conducted a systematic review to determine the most frequent diseases and clinical presentations associated with diagnostic errors (and resulting harms) in the ED, measure error and harm frequency, as well as assess causal factors. METHODS: We searched PubMed(r), Cumulative Index to Nursing and Allied Health Literature (CINAHL(r)), and Embase(r) from January 2000 through September 2021. We included research studies and targeted grey literature reporting diagnostic errors or misdiagnosis-related harms in EDs in the United States or other developed countries with ED care deemed comparable by a technical expert panel. We applied standard definitions for diagnostic errors, misdiagnosis-related harms (adverse events), and serious harms (permanent disability or death). Preventability was determined by original study authors or differences in harms across groups. Two reviewers independently screened search results for eligibility; serially extracted data regarding common diseases, error/harm rates, and causes/risk factors; and independently assessed risk of bias of included studies. We synthesized results for each question and extrapolated U.S. estimates. We present 95 percent confidence intervals (CIs) or plausible range (PR) bounds, as appropriate. RESULTS: We identified 19,127 citations and included 279 studies. The top 15 clinical conditions associated with serious misdiagnosis-related harms (accounting for 68% [95% CI 66 to 71] of serious harms) were (1) stroke, (2) myocardial infarction, (3) aortic aneurysm and dissection, (4) spinal cord compression and injury, (5) venous thromboembolism, (6/7 - tie) meningitis and encephalitis, (6/7 - tie) sepsis, (8) lung cancer, (9) traumatic brain injury and traumatic intracranial hemorrhage, (10) arterial thromboembolism, (11) spinal and intracranial abscess, (12) cardiac arrhythmia, (13) pneumonia, (14) gastrointestinal perforation and rupture, and (15) intestinal obstruction. Average disease-specific error rates ranged from 1.5 percent (myocardial infarction) to 56 percent (spinal abscess), with additional variation by clinical presentation (e.g., missed stroke average 17%, but 4% for weakness and 40% for dizziness/vertigo). There was also wide, superimposed variation by hospital (e.g., missed myocardial infarction 0% to 29% across hospitals within a single study). An estimated 5.7 percent (95% CI 4.4 to 7.1) of all ED visits had at least one diagnostic error. Estimated preventable adverse event rates were as follows: any harm severity (2.0%, 95% CI 1.0 to 3.6), any serious harms (0.3%, PR 0.1 to 0.7), and deaths (0.2%, PR 0.1 to 0.4). While most disease-specific error rates derived from mainly U.S.-based studies, overall error and harm rates were derived from three prospective studies conducted outside the United States (in Canada, Spain, and Switzerland, with combined n=1,758). If overall rates are generalizable to all U.S. ED visits (130 million, 95% CI 116 to 144), this would translate to 7.4 million (PR 5.1 to 10.2) ED diagnostic errors annually; 2.6 million (PR 1.1 to 5.2) diagnostic adverse events with preventable harms; and 371,000 (PR 142,000 to 909,000) serious misdiagnosis-related harms, including more than 100,000 permanent, high-severity disabilities and 250,000 deaths. Although errors were often multifactorial, 89 percent (95% CI 88 to 90) of diagnostic error malpractice claims involved failures of clinical decision-making or judgment, regardless of the underlying disease present. Key process failures were errors in diagnostic assessment, test ordering, and test interpretation. Most often these were attributed to inadequate knowledge, skills, or reasoning, particularly in "atypical" or otherwise subtle case presentations. Limitations included use of malpractice claims and incident reports for distribution of diseases leading to serious harms, reliance on a small number of non-U.S. studies for overall (disease-agnostic) diagnostic error and harm rates, and methodologic variability across studies in measuring disease-specific rates, determining preventability, and assessing causal factors. CONCLUSIONS: Although estimated ED error rates are low (and comparable to those found in other clinical settings), the number of patients potentially impacted is large. Not all diagnostic errors or harms are preventable, but wide variability in diagnostic error rates across diseases, symptoms, and hospitals suggests improvement is possible. With 130 million U.S. ED visits, estimated rates for diagnostic error (5.7%), misdiagnosis-related harms (2.0%), and serious misdiagnosis-related harms (0.3%) could translate to more than 7 million errors, 2.5 million harms, and 350,000 patients suffering potentially preventable permanent disability or death. Over two-thirds of serious harms are attributable to just 15 diseases and linked to cognitive errors, particularly in cases with "atypical" manifestations. Scalable solutions to enhance bedside diagnostic processes are needed, and these should target the most commonly misdiagnosed clinical presentations of key diseases causing serious harms. New studies should confirm overall rates are representative of current U.S.-based ED practice and focus on identified evidence gaps (errors among common diseases with lower-severity harms, pediatric ED errors and harms, dynamic systems factors such as overcrowding, and false positives). Policy changes to consider based on this review include: (1) standardizing measurement and research results reporting to maximize comparability of measures of diagnostic error and misdiagnosis-related harms; (2) creating a National Diagnostic Performance Dashboard to track performance; and (3) using multiple policy levers (e.g., research funding, public accountability, payment reforms) to facilitate the rapid development and deployment of solutions to address this critically important patient safety concern.

Diagnostic errors.

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The use of infrared tympanic thermometry has become a common method of measuring body temperature in Norwegian hospitals. This report summarizes the documentation of diagnostic accuracy of infrared tympanic thermometry compared to rectal thermometry to identify fever among adult patients in hospital or in nursing homes. In addition we have searched for studies that compare oral, axillary and temporal thermometry with rectal thermometry. The review shows that the diagnostic accuracy of tympanic thermometry compared to rectal thermometry is sparsely documented. We identified eleven small cross-sectional studies (N=1426). Most studies evaluated tympanic thermometry, some evaluated oral or axillary thermometry. No studies evaluated temporal thermometry. Correct and observer-independent use of infrared tympanic thermometry can be challenging in a clinical setting. Comparing temperature measurements of different body sites might also be problematic, because the measurements at different sites are all estimates for what we wish to know, the core temperature. Although rectal measurements are considered as reference standard in this review, we acknowledge that this is imperfect in many ways. The studies showed that in general, infrared tympanic thermometry did not identify an acceptable part of patients with fever detected by rectal thermometry (low sensitivity). Infrared tympanic thermometry resulted in few false positive readings (high specificity). Since the studies included few patients with fever measured rectally and had different cut offs for fever, the sensitivity values are uncertain. Given the widespread use of infrared tympanic thermometers, further documentation of diagnostic accuracy and repeatability of newer models used in a clinical setting is needed.

Diagnostic errors.

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Artifacts --- Diagnostic Errors --- Radiography

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"In "Avoiding Errors in Radiology", the authors provide 116 real-life examples of errors from both diagnostic and interventional radiology. In each case, the authors discuss in detail the context in which the errors were made, the resulting complications, and strategies for future prevention. With the cases organized by body region, the authors begin with the cranium and then move to cases of the breast, chest and abdomen, spinal column, musculoskeletal and vascular systems. This book offers the readers: - To inform themselves "without an audience" about possible errors that can happen to every radiologist - To analyze the possible causes of errors and wrong decisions in 116 case studies with over 940 illustrations and to transfer the strategies described to avoid errors into their own work - To limit errors and to deal with them more competently and confidently"--Provided by publisher.

Diagnostic imaging --- Diagnostic errors

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Diagnostic errors --- Diagnostic ultrasonic imaging --- Artifacts --- Diagnostic Errors --- Ultrasonography --- Atlases