Table 3.
Signals of potential inpatient diagnostic error.
| Criteria amenable to automated detection | |||
|---|---|---|---|
| Category | Unique concepts | Specific wording | Study(ies) used |
| Patient deterioration: Indicators of patient status | Death | Death | Mills [8], Hiatt et al. [10], Brennan et al. [11], De Meester et al. [21], O'Leary et al. [23], Pavão et al. [24], Cappuccio et al. [28], Mitchell et al. [31], Williams et al. [32], Resar et al. [35], Herrera-Kiengelher et al. [36], Chapman et al. [40], Murff et al. [41], Wolff et al. [42], Thomas et al. [43], Bates et al. [44], Wolff [45], Bates et al. [46], Craddick and Bader [48] |
| Unexpected death | Wilson et al. [13], Baker et al. [16], Wilson et al. [25], Letaief et al. [26], Soop et al. [29], Kobayashi et al. [30], Mitchell et al. [31], Sari et al. [33], Zegers et al. [34], Forster et al. [38], Michel et al. [39] | ||
| Cardiac/respiratory arrest | Cardiorespiratory arrest | Mills [8], Hiatt et al. [10], Brennan et al. [11], Wilson et al. [13], Baker et al. [16], Classen et al. [18], O'Leary et al. [23], Wilson et al. [25], Letaief et al. [26], Naessens et al. [27], Cappuccio et al. [28], Soop et al. [29], Kobayashi et al. [30], Williams et al. [32], Sari et al. [33], Zegers et al. [34], Forster et al. [38], Michel et al. [39], Chapman et al. [40], Murff et al. [41], Wolff et al. [42], Thomas et al. [43], Bates et al. [44], Wolff [45], Bates et al. [46], Craddick and Bader [48] | |
| Patient deterioration: Indicators of clinical management | Activation of teams responding to acute patient decompensation | Code, rapid response, or medical emergency team activation | Classen et al. [18], De Meester et al. [21], Hwang et al. [22], Naessens et al. [27], Mitchell et al. [31], Resar et al. [35], Braithwaite et al. [37] |
| Increased acuity of care | (Unplanned) transfer to a higher level of care (to intensive, semi-intensive, special, intermediate, or acute care unit) | Mills [8], Hiatt et al. [10], Brennan et al. [11], Wilson et al. [13], Baker et al. [16], Classen et al. [18] (GTT), De Meester et al. [21], Hwang et al. [22], O'Leary et al. [23], Pavão et al. [24], Wilson et al. [25], Letaief et al. [26], Cappuccio et al. [28], Soop et al. [29], Kobayashi et al. [30], Mitchell et al. [31], Sari et al. [33], Zegers et al. [34], Resar et al. [35], Herrera-Kiengelher et al. [36], Michel et al. [39], Murff et al. [41], Wolff et al. [42], Thomas et al. [43], Bates et al. [44], Wolff [45], Bates et al. [46], Craddick and Bader [48] | |
| Intubation | Intubation/re-intubation | Classen et al. [18], Hwang et al. [22], Naessens et al. [27], Resar et al. [35] | |
| New dialysis | New dialysis | O'Leary et al. [23], Resar et al. [35] | |
| Unexpected surgery or other procedure | Unplanned visit to operating room or elsewhere for procedure | Williams et al. [32], Forster et al. [38], Michel et al. [39], Chapman et al. [40] | |
| Change of code status | Code status change in the unit | Resar et al. [35] | |
| Unexpected time course of illness: Ongoing symptoms necessitating re-presentation | Subsequent readmission | (Unplanned) readmission after discharge | Mills [8], Hiatt et al. [10], Brennan et al. [11], Wilson et al. [13], Baker et al. [16], O'Leary et al. [23], Wilson et al. [25], Letaief et al. [26], Soop et al. [29], Zegers et al. [34], Thomas et al. [43], Bates et al. [44] |
| Readmission within 12 months | Pavão et al. [24], Kobayashi et al. [30] | ||
| Readmission within 30 days | Classen et al. [18], Hwang et al. [22], Naessens et al. [27], Cappuccio et al. [28] | ||
| Readmission within 28 days | Wolff [45] | ||
| Readmission within 21 days | Wolff et al. [42] | ||
| Readmission within 15 days | Herrera-Kiengelher et al. [36] | ||
| Readmission within 72 h | Mitchell et al. [31] | ||
| Readmission causally associated with first admission | Unplanned readmission related to the care provided in the index admission | Sari et al. [33] | |
| Subsequent outpatient or ED visit because of complications | Subsequent visit to ER or outpatient doctor for complication or adverse results related to this hospitalization | Craddick and Bader [48] | |
| Unexpected time course of illness: Prolonged hospitalization | LOS longer than threshold number of days | Length of stay >35 days | Wolff [45] |
| LOS >30 days | Herrera-Kiengelher et al. [36] | ||
| LOS >21 days | Wolff et al. [42] | ||
| LOS >10 days | Williams et al. [32], Chapman et al. [40] | ||
| Unspecified threshold, to be determined by hospital | Craddick and Bader [48] | ||
| >7 days in ICU | Resar et al. [35] | ||
| LOS longer than expected | LOS longer than expected | Williams et al. [32], Chapman et al. [40] | |
| LOS >50% longer than expected | Cihangir et al. [20] | ||
| LOS longer than percentile for DRG | LOS >90th percentile for DRG in patients under 70, and 95th percentile in those 70 or older | Hiatt et al. [10] | |
| LOS >90th percentile | Mills [8] | ||
| Unspecified threshold, to be determined by hospital | Craddick and Bader [48] | ||
| Change of management: Facility or provider | Change of facility | Unplanned transfer to another hospital/acute care hospital or facility | Mills [8], Hiatt et al. [10], Brennan et al. [11], Wilson et al. [13], Baker et al. [16], O'Leary et al. [23], Pavão et al. [24], Wilson et al. [25], Letaief et al. [26], Soop et al. [29], Kobayashi et al. [30], Williams et al. [32], Sari et al. [33], Herrera-Kiengelher et al. [36], Michel et al. [39], Chapman et al. [40], Wolff et al. [42], Thomas et al. [43], Bates et al. [44], Wolff [45], Wolff [45], Craddick and Bader [48] |
| Change of physician or team | Abrupt change of physician in charge | Resar et al. [35] | |
| Change of management: Specific treatment plan | Change of medical treatment | Abrupt medication stop | Classen et al. [18], Hwang et al. [22], O'Leary et al. [23], Naessens et al. [27], Cappuccio et al. [28] |
| Change of management: Change in procedure diagnosis or type | Change of procedural treatment | Change in procedure | Classen et al. [18], Hwang et al. [22], Naessens et al. [27] |
| Cancellation of procedure | Patient booked for surgery and cancelled | Wolff [45] | |
| Difference between diagnosis and pathology results | Pathology report normal or unrelated to diagnosis | Classen et al. [18], Naessens et al. [27] | |
| Diagnostic uncertainty | Multiple consultations | 3 or more consultants | Resar et al. [35] |
| Criteria not likely available in electronic format | |||
| Clinical judgment needed for interpretation | Delays in diagnosis/detection | Diagnosis significantly delayed at any stage of admission | Williams et al. [32] |
| Other diagnostic error | Diagnostic error – missed, delayed, misdiagnosis | Mitchell et al. [31] | |
| Delay in initiating effective treatment | Significant delay in diagnosis/initiating effective treatment at any stage of admission | Chapman et al. [40] | |
| Abnormal results not addressed by provider | Abnormal laboratory, medical imaging, physical findings or other tests not followed up or addressed | Mitchell et al. [31], Craddick and Bader [48] | |
| Inadequate observation | Patient deterioration, death, or medical emergency team referral after inadequate observation process | Mitchell et al. [31] | |
| Undefined deterioration | Worsening condition | Herrera-Kiengelher et al. [36] | |
| Documented pain or psychological or social injury | Michel et al. [39] | ||
| Dissatisfaction with care | Patient dissatisfaction | Dissatisfaction with care received as documented on patient record, or evidence of complaint lodged | Wilson et al. [13], Baker et al. [16], Pavão et al. [24], Letaief et al. [26], Soop et al. [29], Kobayashi et al. [30], Williams et al. [32], Sari et al. [33], Zegers et al. [34], Herrera-Kiengelher et al. [36], Michel et al. [39], Chapman et al. [40] |
| Family complaints about care | Relative made complaint regarding care | Wilson et al. [25], Williams et al. [32], Resar et al. [35], Forster et al. [38], Michel et al. [39], Chapman et al. [40], Craddick and Bader [48] | |
| Patient pursuing litigation | Documentation or correspondence suggesting/indicating litigation (either contemplated or actual) | Hiatt et al. [10], Wilson et al. [13], Baker et al. [16], Pavão et al. [24], Wilson et al. [25], Letaief et al. [26], Soop et al. [29], Kobayashi et al. [30], Sari et al. [33], Zegers et al. [34], Herrera-Kiengelher et al. [36], Forster et al. [38], Michel et al. [39], Thomas et al. [43], Bates et al. [44] | |
| Provider dissatisfaction | Doctor or nurse unhappy about any aspect of care | Williams et al. [32], Chapman et al. [40] | |
| Reporting external to EHR | Referral to hospital ethics board | Specific case referral | Mitchell et al. [31] |
| Incident report to external board | High-level incident report | Mitchell et al. [31] | |