TY - JOUR
T1 - What Can We Learn from In-Depth Analysis of Human Errors Resulting in Diagnostic Errors in the Emergency Department
T2 - An Analysis of Serious Adverse Event Reports
AU - Baartmans, Mees C.
AU - Hooftman, Jacky
AU - Zwaan, Laura
AU - Van Schoten, Steffie M.
AU - Erwich, Jan Jaap H.M.
AU - Wagner, Cordula
N1 - Funding Information: The study was funded by the Dutch Ministry of Health, Welfare and Sport, no grant/award number applicable. L.Z. is additionally supported by a Veni grant from the Dutch National Scientific Organization (Nederlandse Organisatie voor Wetenschappelijk Onderzoek; 45116032). Publisher Copyright: © Wolters Kluwer Health, Inc. All rights reserved.
PY - 2022/12/1
Y1 - 2022/12/1
N2 - Introduction Human error plays a vital role in diagnostic errors in the emergency department. A thorough analysis of these human errors, using information-rich reports of serious adverse events (SAEs), could help to better study and understand the causes of these errors and formulate more specific recommendations. Methods We studied 23 SAE reports of diagnostic events in emergency departments of Dutch general hospitals and identified human errors. Two researchers independently applied the Safer Dx Instrument, Diagnostic Error Evaluation and Research Taxonomy, and the Model of Unsafe acts to analyze reports. Results Twenty-one reports contained a diagnostic error, in which we identified 73 human errors, which were mainly based on intended actions (n=69) and could be classified as mistakes (n=56) or violations (n=13). Most human errors occurred during the assessment and testing phase of the diagnostic process. Discussion The combination of different instruments and information-rich SAE reports allowed for a deeper understanding of the mechanisms underlying diagnostic error. Results indicated that errors occurred most often during the assessment and the testing phase of the diagnostic process. Most often, the errors could be classified as mistakes and violations, both intended actions. These types of errors are in need of different recommendations for improvement, as mistakes are often knowledge based, whereas violations often happen because of work and time pressure. These analyses provided valuable insights for more overarching recommendations to improve diagnostic safety and would be recommended to use in future research and analysis of (serious) adverse events.
AB - Introduction Human error plays a vital role in diagnostic errors in the emergency department. A thorough analysis of these human errors, using information-rich reports of serious adverse events (SAEs), could help to better study and understand the causes of these errors and formulate more specific recommendations. Methods We studied 23 SAE reports of diagnostic events in emergency departments of Dutch general hospitals and identified human errors. Two researchers independently applied the Safer Dx Instrument, Diagnostic Error Evaluation and Research Taxonomy, and the Model of Unsafe acts to analyze reports. Results Twenty-one reports contained a diagnostic error, in which we identified 73 human errors, which were mainly based on intended actions (n=69) and could be classified as mistakes (n=56) or violations (n=13). Most human errors occurred during the assessment and testing phase of the diagnostic process. Discussion The combination of different instruments and information-rich SAE reports allowed for a deeper understanding of the mechanisms underlying diagnostic error. Results indicated that errors occurred most often during the assessment and the testing phase of the diagnostic process. Most often, the errors could be classified as mistakes and violations, both intended actions. These types of errors are in need of different recommendations for improvement, as mistakes are often knowledge based, whereas violations often happen because of work and time pressure. These analyses provided valuable insights for more overarching recommendations to improve diagnostic safety and would be recommended to use in future research and analysis of (serious) adverse events.
KW - adverse event
KW - diagnostic error
KW - diagnostic safety
KW - emergency department
KW - human error
KW - root cause analysis
UR - http://www.scopus.com/inward/record.url?scp=85143379852&partnerID=8YFLogxK
U2 - https://doi.org/10.1097/PTS.0000000000001007
DO - https://doi.org/10.1097/PTS.0000000000001007
M3 - Article
C2 - 35443259
SN - 1549-8417
VL - 18
SP - e1135-e1141
JO - Journal of Patient Safety
JF - Journal of Patient Safety
IS - 8
ER -