What Can We Learn from In-Depth Analysis of Human Errors Resulting in Diagnostic Errors in the Emergency Department: An Analysis of Serious Adverse Event Reports

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.