title: Diagnostic errors related to acute abdominal pain in the emergency department.
abstract: OBJECTIVE
  Diagnostic errors in the emergency department (ED) are harmful and costly. We reviewed a selected high-risk cohort of patients presenting to the ED with abdominal pain to evaluate for possible diagnostic errors and associated process breakdowns.
  
  
  METHODS
  We conducted a retrospective chart review of ED patients >18 years at an urban academic hospital. A computerised 'trigger' algorithm identified patients possibly at high risk for diagnostic errors to facilitate selective record reviews. The trigger determined patients to be at high risk because they: (1) presented to the ED with abdominal pain, and were discharged home and (2) had a return ED visit within 10 days that led to a hospitalisation. Diagnostic errors were defined as missed opportunities to make a correct or timely diagnosis based on the evidence available during the first ED visit, regardless of patient harm, and included errors that involved both ED and non-ED providers. Errors were determined by two independent record reviewers followed by team consensus in cases of disagreement.
  
  
  RESULTS
  Diagnostic errors occurred in 35 of 100 high-risk cases. Over two-thirds had breakdowns involving the patient-provider encounter (most commonly history-taking or ordering additional tests) and/or follow-up and tracking of diagnostic information (most commonly follow-up of abnormal test results). The most frequently missed diagnoses were gallbladder pathology (n=10) and urinary infections (n=5).
  
  
  CONCLUSIONS
  Diagnostic process breakdowns in ED patients with abdominal pain most commonly involved history-taking, ordering insufficient tests in the patient-provider encounter and problems with follow-up of abnormal test results.
authors.affiliation: Department of Emergency Medicine, Robert Wood Johnson Foundation Clinical Scholars, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
authors.forename: Laura
authors.initials: L
authors.lastname: Medford-Davis
authors.affiliation: Section of Emergency Medicine, Baylor College of Medicine and Harris Health System, Ben Taub General Hospital Emergency Center, Houston, Texas, USA.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Park
authors.affiliation: Department of Emergency Medicine, University of Southern California Keck School of Medicine, Los Angeles, California, USA.
authors.forename: Gil
authors.initials: G
authors.lastname: Shlamovitz
authors.affiliation: Michael E DeBakey Department of Surgery, Baylor College of Medicine and Harris Health System, Houston, Texas, USA.
authors.forename: James
authors.initials: J
authors.lastname: Suliburk
authors.affiliation: Houston Veterans Affairs Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas, USA.
authors.forename: Ashley N D
authors.initials: AN
authors.lastname: Meyer
authors.affiliation: Houston Veterans Affairs Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas, USA.
authors.forename: Hardeep
authors.initials: H
authors.lastname: Singh
mesh_terms: D015746:Abdominal Pain / Q000175:diagnosis* / Q000209:etiology; D000328:Adult; D000368:Aged; D003951:Diagnostic Errors / Q000706:statistics & numerical data*; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D005705:Gallbladder Diseases / Q000175:diagnosis; D006786:Hospitals, Urban / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008487:Medical History Taking; D008875:Middle Aged; D010351:Patient Discharge; D017064:Process Assessment, Health Care / Q000706:statistics & numerical data; D012189:Retrospective Studies; D014481:United States; D014552:Urinary Tract Infections / Q000175:diagnosis
keywords: abdomen- non trauma; diagnosis; errors; quality assurance; safety