The National Academy of Medicine (NAM) has called diagnostic error a "blind spot" for modern medicine and improving diagnosis a "moral, professional, and public health imperative."9 The emergency department (ED) is a known high-risk site for diagnostic error.10-15The key decisional dilemma for this evidence review is "What are the most common and significant medical diagnostic failures in the ED, and why does this happen?" The goal is to determine the following: (1) What are the most frequent signs and symptoms and clinical conditions that are associated with diagnostic errors in the ED and urgent care settings?; (2) For specific clinical conditions, what are the factors associated with diagnostic errors in the ED and urgent care settings?; (3) Are there commonalities across clinical conditions associated with diagnostic errors in the ED and urgent care settings?
Draft Key Questions
Key Question 1: What clinical conditions are associated with the greatest number of diagnostic errors and serious misdiagnosis-related harms in the ED? Prospectively analyzed subgroups will include the following:
- Adults (≥18yo) vs. children (<18yo)
- ED discharges vs. admissions
- Physicians vs. advanced practice providers
- Providers who are trained vs. not trained in emergency medicine
- Studies conducted in United States vs. non-United States
Key Question 2: Overall and for the clinical conditions identified from KQ1, how common are ED diagnostic errors and serious misdiagnosis-related harms?
- How were diagnostic errors and harms defined and identified?
- How were diagnostic errors and harms categorized?
- What are the most frequent clinical presenting symptoms or signs that are associated with diagnostic errors in the ED?
- Are there key commonalities or differences among frequencies of ED diagnostic errors across clinical conditions?
Key Question 3: Overall and for the clinical conditions identified from KQ1, what are the key causal factors associated with ED diagnostic errors and serious misdiagnosis-related harms?
- What methods were used to investigate causes?
- How were causes categorized?
- What were the most frequent causes identified?
- Do different causes have differential impact on patient outcomes (harms)?
- Overall and for each clinical condition:
- What patient characteristics are associated with errors/harms? In particular, are there associations with age, gender, language, socioeconomic status/income, literacy, racial/ethnic characteristics?
- What clinician characteristics are associated with errors/harms?
- What facility or health system characteristics are associated with errors/harms?
- Are there key commonalities or differences among causes of ED diagnostic errors across clinical conditions?
Serious misdiagnosis-related harms are defined to include death or permanent disability (NAIC scale 6–9). Clinical conditions anticipated to top the list are vascular events (stroke, myocardial infarction, venous thromboembolism, aortic aneurysm and dissection, arterial thromboembolism), infections (sepsis, meningitis and encephalitis, spinal abscess, pneumonia, endocarditis, and appendicitis), and fractures. Additional conditions that are likely relevant to a pediatric population include testicular torsion, necrotizing enterocolitis, and sudden cardiac death/arrythmias/congenital heart disease. The results of KQ1's search will inform whether any additional conditions are added to the initial list of 15 conditions for KQ2/KQ3. We will exclude specialty EDs (e.g., eye and ear) from the primary analysis.
Figure 1: Draft Analytic Framework
- From the perspective of the health system
- In the ED
- Diagnostic error/misdiagnosis-related harms
- Within the environment of hospital and health systems based in the United States, Canada, UK, Western Europe, Australia/New Zealand, Taiwan, South Korea, and Japan.
- We will include studies from 2000 to present. There will be a comparison of studies between 2000–2010 to 2011–2021.
- List of key diseases and clinical conditions accounting for the majority of serious misdiagnosis-related harms
- Frequency of diagnostic errors and serious misdiagnosis-related harms overall and for key clinical conditions
- Patient, clinician, facility and health system characteristics that are associated with diagnostic errors/harms
Definition of Terms
ED = emergency department
NAM = National Academy of Medicine
SPADE = Symptom-disease Pair Analysis of Diagnostic Error
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