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Diagnostic adverse events associated with severe, highly preventable outcomes
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Adverse events due to diagnostic error produced more severe consequences compared with other adverse events and were considered to be preventable in most instances, new study data indicated.
The study featured a systematic three-stage retrospective review that included records (n=7,926) of discharged and deceased patients admitted to 21 Dutch acute care hospitals in 2004. Using protocol developed by the Harvard Medical Practice Study, the physicians reviewed randomly selected hospital records and selected all adverse events with diagnostic error as the main category for analysis and compared them with other adverse event types.
Diagnostic adverse events occurred in 0.4% (95% CI, 0.21%-0.59%) of hospital admissions and represented 6.4% (95% CI, 4.3%-8.5%) of all adverse events. Of the diagnostic adverse events, researchers determined 83.3% were preventable. Human failure was identified as the main cause (96.3%), although factors relating to organization (25%) and the patients (30%) contributed. In addition, the consequences of diagnostic adverse events had a higher mortality rate than for other adverse events (29.1% vs. 7.4%).
“[Diagnostic adverse events] are an important [adverse event] type because they are considered to be highly preventable and their consequences are severe,” the researchers wrote. “The causes of human and organizational categories suggest a chain of events that lead to [diagnostic adverse events], the main causes being knowledge-based mistakes combined with verification and information transfer problems. Prevention strategies should focus on better training of physicians in a context-specific manner and on organization of knowledge and information transfer.”
Zwaan L. Arch Intern Med. 2010;170:1015-1021.