Identifying trigger concepts to screen emergency department visits for diagnostic errors

doi:10.1515/dx-2020-0122

Review

. 2020 Nov 13;8(3):340-346.

doi: 10.1515/dx-2020-0122. Print 2021 Aug 26.

Identifying trigger concepts to screen emergency department visits for diagnostic errors

Prashant Mahajan¹, Chih-Wen Pai¹, Karen S Cosby², Cynthia J Mollen³, Kathy N Shaw³, James M Chamberlain⁴, Robert El-Kareh⁵, Richard M Ruddy⁶, Elizabeth R Alpern⁷, Helene M Epstein⁸, Traber D Giardina⁹, Mark L Graber¹⁰, Laura N Medford-Davis¹¹, Richard P Medlin¹, Divvy K Upadhyay¹², Sarah J Parker¹, Hardeep Singh⁹

Affiliations

¹ Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA.
² Department of Emergency Medicine, Cook County Hospital (Stroger), Rush Medical College, Chicago, IL, USA.
³ Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
⁴ Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's National Medical Center, Washington, DC, USA.
⁵ UCSD Health Department of Biomedical Informatics, University of California San Diego, La Jolla, CA, USA.
⁶ Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
⁷ Division of Pediatric Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
⁸ Board of Directors, Brightpoint Care, New York, NY, USA (Subsidiary, Sun River Health, Peekskill, NY, USA).
⁹ Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX, USA.
¹⁰ Society to Improve Diagnosis in Medicine, RTI International, Plymouth, MA, USA.
¹¹ Department of Emergency Medicine, Baylor College of Medicine, Houston, TX, USA.
¹² Division of Quality, Safety and Patient Experience, Geisinger, Danville, PA, USA.

PMID: 33180032
DOI: 10.1515/dx-2020-0122

Review

Identifying trigger concepts to screen emergency department visits for diagnostic errors

Prashant Mahajan et al. Diagnosis (Berl). 2020.

. 2020 Nov 13;8(3):340-346.

doi: 10.1515/dx-2020-0122. Print 2021 Aug 26.

Authors

Affiliations

¹ Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA.
² Department of Emergency Medicine, Cook County Hospital (Stroger), Rush Medical College, Chicago, IL, USA.
³ Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
⁴ Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's National Medical Center, Washington, DC, USA.
⁵ UCSD Health Department of Biomedical Informatics, University of California San Diego, La Jolla, CA, USA.
⁶ Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
⁷ Division of Pediatric Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
⁸ Board of Directors, Brightpoint Care, New York, NY, USA (Subsidiary, Sun River Health, Peekskill, NY, USA).
⁹ Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX, USA.
¹⁰ Society to Improve Diagnosis in Medicine, RTI International, Plymouth, MA, USA.
¹¹ Department of Emergency Medicine, Baylor College of Medicine, Houston, TX, USA.
¹² Division of Quality, Safety and Patient Experience, Geisinger, Danville, PA, USA.

PMID: 33180032
DOI: 10.1515/dx-2020-0122

Abstract

Objectives: The diagnostic process is a vital component of safe and effective emergency department (ED) care. There are no standardized methods for identifying or reliably monitoring diagnostic errors in the ED, impeding efforts to enhance diagnostic safety. We sought to identify trigger concepts to screen ED records for diagnostic errors and describe how they can be used as a measurement strategy to identify and reduce preventable diagnostic harm.

Methods: We conducted a literature review and surveyed ED directors to compile a list of potential electronic health record (EHR) trigger (e-triggers) and non-EHR based concepts. We convened a multidisciplinary expert panel to build consensus on trigger concepts to identify and reduce preventable diagnostic harm in the ED.

Results: Six e-trigger and five non-EHR based concepts were selected by the expert panel. E-trigger concepts included: unscheduled ED return to ED resulting in hospital admission, death following ED visit, care escalation, high-risk conditions based on symptom-disease dyads, return visits with new diagnostic/therapeutic interventions, and change of treating service after admission. Non-EHR based signals included: cases from mortality/morbidity conferences, risk management/safety office referrals, ED medical director case referrals, patient complaints, and radiology/laboratory misreads and callbacks. The panel suggested further refinements to aid future research in defining diagnostic error epidemiology in ED settings.

Conclusions: We identified a set of e-trigger concepts and non-EHR based signals that could be developed further to screen ED visits for diagnostic safety events. With additional evaluation, trigger-based methods can be used as tools to monitor and improve ED diagnostic performance.

Keywords: diagnostic error; emergency department; patient safety; trigger concepts.

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References

1. Institute of Medicine. Emergency care for children: growing pains. Washington, DC: National Academies Press; 2007. https://doi.org/10.17226/11655.
1. Institute of Medicine. Hospital based emergency care: at the breaking point. Washington, DC: National Academies Press; 2007. https://doi.org/10.17226/11621.
1. Institute of Medicine. Emergency medical services: at the crossroads. Washington, DC: National Academies Press; 2007. https://doi.org/10.17226/11629.
1. National Academies of Sciences. Engineering, and Medicine. Improving diagnosis in health care. In: Balogh, EP, Miller, BT, Ball, JR, editors. Washington, DC: The National Academies Press; 2015.
1. National Quality Forum. Improving diagnostic quality and safety. Washington, DC: National Quality Forum; 2017.

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[1] Institute of Medicine. Emergency care for children: growing pains. Washington, DC: National Academies Press; 2007. https://doi.org/10.17226/11655.

[2] Institute of Medicine. Emergency care for children: growing pains. Washington, DC: National Academies Press; 2007. https://doi.org/10.17226/11655.

[3] Institute of Medicine. Hospital based emergency care: at the breaking point. Washington, DC: National Academies Press; 2007. https://doi.org/10.17226/11621.

[4] Institute of Medicine. Hospital based emergency care: at the breaking point. Washington, DC: National Academies Press; 2007. https://doi.org/10.17226/11621.

[5] Institute of Medicine. Emergency medical services: at the crossroads. Washington, DC: National Academies Press; 2007. https://doi.org/10.17226/11629.

[6] Institute of Medicine. Emergency medical services: at the crossroads. Washington, DC: National Academies Press; 2007. https://doi.org/10.17226/11629.

[7] National Academies of Sciences. Engineering, and Medicine. Improving diagnosis in health care. In: Balogh, EP, Miller, BT, Ball, JR, editors. Washington, DC: The National Academies Press; 2015.

[8] National Academies of Sciences. Engineering, and Medicine. Improving diagnosis in health care. In: Balogh, EP, Miller, BT, Ball, JR, editors. Washington, DC: The National Academies Press; 2015.

[9] National Quality Forum. Improving diagnostic quality and safety. Washington, DC: National Quality Forum; 2017.

[10] National Quality Forum. Improving diagnostic quality and safety. Washington, DC: National Quality Forum; 2017.

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Identifying trigger concepts to screen emergency department visits for diagnostic errors

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Identifying trigger concepts to screen emergency department visits for diagnostic errors

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