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An Operational Framework to Study Diagnostic Errors in Emergency Departments

Findings From A Consensus Panel

Mahajan, Prashant MD, MPH, MBA*,†; Mollen, Cynthia MD; Alpern, Elizabeth R. MD, MSCE§; Baird-Cox, Kelly DNP, RN, CPNP, CPEN, CEN, TCRN, NEA-BC, CENP*; Boothman, Richard C. JD; Chamberlain, James M. MD; Cosby, Karen MD**; Epstein, Helene M. BS††; Gegenheimer-Holmes, Jennifer RN BSN MHSA CEN*; Gerardi, Michael MD§§; Giardina, Traber D. PhD, MSW∥∥; Patel, Vimla L. PhD, DSc¶¶; Ruddy, Richard MD***; Saleem, Jason PhD†††; Shaw, Kathy N. MD, MSCE; Sittig, Dean F. PhD‡‡‡; Singh, Hardeep MD, MPH∥∥

doi: 10.1097/PTS.0000000000000624
Original Article: PDF Only

Objective To create an operational definition and framework to study diagnostic error in the emergency department setting.

Methods We convened a 17-member multidisciplinary panel with expertise in general and pediatric emergency medicine, nursing, patient safety, informatics, cognitive psychology, social sciences, human factors, and risk management and a patient/caregiver advocate. We used a modified nominal group technique to develop a shared understanding to operationally define diagnostic errors in emergency care and modify the National Academies of Sciences, Engineering, and Medicine's conceptual process framework to this setting.

Results The expert panel defined diagnostic errors as “a divergence from evidence-based processes that increases the risk of poor outcomes despite the availability of sufficient information to provide a timely and accurate explanation of the patient's health problem(s).” Diagnostic processes include tasks related to (a) acuity recognition, information and synthesis, evaluation coordination, and (b) communication with patients/caregivers and other diagnostic team members. The expert panel also modified the National Academies of Sciences, Engineering, and Medicine's diagnostic process framework to incorporate influence of mode of arrival, triage level, and interventions during emergency care and underscored the importance of outcome feedback to emergency department providers to promote learning and improvement related to diagnosis.

Conclusions The proposed operational definition and modified diagnostic process framework can potentially inform the development of measurement tools and strategies to study the epidemiology and interventions to improve emergency care diagnosis.

From the Departments of *Emergency Medicine

Pediatrics, University of Michigan, Ann Arbor, Michigan

Division of Pediatric Emergency Medicine, Department Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania

§Division of Pediatric Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois

Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan

Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's National Health System, Washington, District of Columbia

**Emergency Medicine, Cook County Hospital (Stroger) and Rush Medical School, Chicago, Illinois

††Member of the Board of Directors, Brightpoint Care, New York, New York

§§Emergency Medicine, Morristown Medical Center and Goryeb Children's Hospital, Morristown, New Jersey

∥∥Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas

¶¶Center for Cognitive Studies in Medicine and Public Health, The New York Academy of Medicine, New York, New York

***University of Cincinnati College of Medicine, Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio

†††Industrial Engineering, University of Louisville, Louisville, Kentucky

‡‡‡School of Biomedical Informatics, University of Texas Health Science Center at Houston, Houston, Texas.

Correspondence: Prashant Mahajan, MD, MPH, MBA, Department of Emergency Medicine, University of Michigan, 1540 E. Hospital Dr, CW 2-737, Ann Arbor, MI 48109-4260 (e-mail:

The study was supported by the Agency for Healthcare Research and Quality (Grant Number R01HS024953). The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality. H.S. is also partially supported by the Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety (CIN 13-413).

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