Diagnostic errors are associated with patient harm and often preventable

January 01, 0001

Diagnostic errors are associated with patient harm and often preventable

Diagnostic errors often result in patient harm. The present study explored diagnostic adverse events (DAEs) across all medical specialties to determine their incidence and to gain insight into their causes and consequences by comparing them with other AE types. The Dutch authors conducted a structured review of 7926 patient records from 21 hospitals across the Netherlands. The method used in this study was based on the well-known protocol developed by the Harvard Medical Practice Study. All AEs with diagnostic error as the main category were selected for analysis and were compared with other AE types.

They found: "Diagnostic AEs occurred in 0.4% of hospital admissions and represented 6.4% of all AEs. Of the DAEs, 83.3% were judged to be preventable. Human failure was identified as the main cause (96.3%), although organizational- and patient-related factors also contributed (25.0% and 30.0%, respectively). The consequences of DAEs were more severe (higher mortality rate) than for other AEs (29.1% vs 7.4%)."

The authors concluded: "Diagnostic AEs represent an important error type, and the consequences of DAEs are severe. The causes of DAEs were mostly human, with the main causes being knowledge-based mistakes and information transfer problems. Prevention strategies should focus on training physicians and on the organization of knowledge and information transfer."

The severity of diagnostic adverse events and their frequently preventable nature give should stimulate further research on interventions to reduce them.

For the full abstract, click here.

Arch Intern Med 170(12):1015-1021, 28 June 2010 © 2010 to the American Medical Association
Patient Record Review of the Incidence, Consequences, and Causes of Diagnostic Adverse Events. Laura Zwaan, Martine de Bruijne, Cordula Wagner, et al. Correspondence to Dr. Zwaan: [email protected]

Category: HSR. Health Services Research. Keywords: diagnosis, error, adverse events, hospital admission, mortality, retrospective chart review, journal watch.
Synopsis edited by Dr Linda French, Toledo, Ohio. Posted on Global Family Doctor 13 July 2010

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