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"Diagnostic errors United States Case studies."
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Brain on fire : my month of madness
\"When twenty-four-year-old Susannah Cahalan woke up alone in a hospital room, strapped to her bed and unable to move or speak, she had no memory of how she'd gotten there. Days earlier, she had been on the threshold of a new, adult life: at the beginning of her first serious relationship and a promising career at a major New York newspaper. Now she was labeled violent, psychotic, a flight risk. What happened? In a swift and breathtaking narrative, [the author] tells the astonishing true story of her descent into madness, her family's inspiring faith in her, and the lifesaving diagnosis that nearly didnt happen\"--Amazon.com.
Book
Unspeakable
Junius Wilson (1908-2001) spent seventy-six years at a state mental hospital in Goldsboro, North Carolina, including six in the criminal ward. He had never been declared insane by a medical professional or found guilty of any criminal charge. But he was deaf and black in the Jim Crow South. Unspeakable is the story of his life.Using legal records, institutional files, and extensive oral history interviews--some conducted in sign language--Susan Burch and Hannah Joyner piece together the story of a deaf man accused in 1925 of attempted rape, found insane at a lunacy hearing, committed to the criminal ward of the State Hospital for the Colored Insane, castrated, forced to labor for the institution, and held at the hospital for more than seven decades. Junius Wilson's life was shaped by some of the major developments of twentieth-century America: Jim Crow segregation, the civil rights movement, deinstitutionalization, the rise of professional social work, and the emergence of the deaf and disability rights movements. In addition to offering a bottom-up history of life in a segregated mental institution, Burch and Joyner's work also enriches the traditional interpretation of Jim Crow by highlighting the complicated intersections of race and disability as well as of community and language. This moving study expands the boundaries of what biography can and should be. There is much to learn and remember about Junius Wilson--and the countless others who have lived unspeakable histories.
eBook
Diagnostic safety in the policy landscape - a comparative policy document analysis of Australian and Aotearoa New Zealand vs US health care and research policy
Background
Diagnostic safety, a subset of patient safety, ensures safe, high-quality care in the diagnostic process e.g. through reporting and evaluating near-misses and errors. It involves healthcare policy (e.g. incident reporting guidelines) and research policy (e.g. research funding). To date, policy attention to diagnostic safety has been limited.
Methods
Across United States (US) versus Australian and Aotearoa New Zealand (AUS/AoNZ) policy contexts, we systematically identified relevant policy documents from national health quality organisations and Emergency Medicine (EM) specialist colleges and compared the development and integration of diagnostic safety into policy. We adopted a directed policy document analytical approach (READ (Ready materials, Extract data, Analyse data, Distil findings) to develop comparative frameworks for diagnostic safety policy and embedded a case study on Emergency Medicine guidelines.
Results
We identified 237 publicly available, written policy documents (AUS/AoNZ:
n
= 151; US:
n
= 86) and 36 EM guidelines AUS/AoNZ:
n
= 16; US:
n
= 20) from national US and AUS/AoNZ health quality organisations and EM specialist colleges. The majority of policy documents (55%) were published between 2019 and 2023. US policy documents had a greater dedicated diagnostic safety focus (
n
= 58, 67%) compared to a generic patient safety focus (
n
= 28; 33%) and had higher emphasis on research compared to diseases. AUS/AoNZ documents focused more on generic patient safety (
n
= 102, 68%) than diagnostic safety (
n
= 49, 32%) and concentrated more on diseases than research. The majority of EM guidelines (AUS/AoNZ: 81%, US: 75%) contained diagnostic safety comments, but overall 20% focused on treatment rather than diagnosis. US EM guidelines showed greater legal considerations.
Conclusions
Awareness of diagnostic safety as reflected in healthcare and research policy is growing. Identifying country-specific differences can inform future strategic policy development and target areas that have received limited attention.
Journal Article
Fumbled Handoffs: One Dropped Ball after Another
Missed follow-up of abnormal test results and resultant delays in diagnosis is a safety issue that is gaining increasing attention. Despite increases in the numbers and types of available diagnostic tests, current systems in health care do not reliably ensure that test results are received and acted upon by ordering physicians. This article examines the case of a patient whose diagnosis of tuberculosis was substantially delayed because of systems problems, including poor continuity (with multiple-provider involvement), lack of communication of test results and other clinical information, and several handoffs. Strategies to ensure adequate communication of critical information and follow-up of test results are discussed, such as explicit criteria for communication of abnormal results, test-tracking systems for ordering providers, and use of information technologies.
Journal Article
Patient Safety and Telephone Medicine
Summary
Objectives
The telephone can facilitate medical care but also result in adverse outcomes leading to telephone-related malpractice suits. Analyzing claims might identify errors amenable to prevention. The objective of the study was to describe medical errors involving the telephone in patient–clinician encounters that significantly impacted medical care and medico-legal outcomes.
Design
The design of the study was a descriptive, retrospective case review of telephone-related closed malpractice claims that included depositions, expert witness testimony, medical records, allegations, injuries, and outcomes.
Patients/Participants
Forty defendants from 32 cases coded specifically as telephone related by a major provider of malpractice insurance. Leading specialists sued: Internists, pediatricians, and obstetricians.
Measurements and Main Results
Cases were reviewed by a physician experienced in telephone medicine and independently checked by a risk management nurse specialist and discussed by 2 additional risk management analysts before arriving at full agreement. Twenty-four (60%) cases were settled or awarded to the plaintiff. The most common allegation was failed diagnosis (68%), most common injury was death (44%), and most common setting was general medicine ambulatory practice. Leading errors were documentation (88%) and faulty triage (84%). The average indemnity was $518,932, with a total indemnity of $12,454,375.
Conclusions
Telephone-related claims were costly; injuries were catastrophic. Poor documentation and faulty triage were major factors influencing care and legal outcome. Telephone errors may represent the tip of the iceberg in patient safety in ambulatory practice; however, these preliminary results need to be confirmed in a larger sample of cases.
Journal Article
Testing for Linkage and Association Across the Dihydrolipoyl Dehydrogenase Gene Region with Alzheimer’s Disease in Three Sample Populations
Prior case-control studies from our laboratory of a population enriched with individuals of Ashkenazi Jewish descent suggested that association exists between Alzheimer's disease (AD) and the chromosomal region near the DLD gene, which encodes the mitochondrial dihydrolipoamide dehydrogenase enzyme. In support of this finding, we found that linkage analysis restricted to autopsy-proven patients in the National Institute of Mental Health-National Cell Repository for Alzheimer's Disease (NIMH-NCRAD) Genetics Initiative pedigree data resulted in point-wise significant evidence for linkage (minimum p-value = 0.024) for a marker position close to the DLD locus. We now report case-control replication studies in two independent Caucasian series from the US and Italy, as well as a linkage analysis from the NIMH-NCRAD Genetics Initiative Database. Pair-wise analysis of the SNPs in the case-control series indicated there was strong linkage disequilibrium across the DLD locus in these populations, as previously reported. These findings suggest that testing for association of complex diseases with DLD locus should have considerable statistical power. Analysis of multi-locus genotypes or haplotypes based upon three SNP loci combined with results from our previous report provided trends toward significant evidence of association of DLD with AD, although neither of the present studies' association showed significance at the 0.05 level. Combining linkage and association findings for all AD patients (males and females) results in a p-value that is more significant than any of the individual findings' p-values. Finally, minimum sample size calculations using parameters from the DLD locus suggest that sample sizes on the order of 1,000 total cases and controls are needed to detect association for a wide range of genetic model parameters.
Journal Article
Diagnosis and Treatment of Idiopathic Normal Pressure Hydrocephalus
Idiopathic normal pressure hydrocephalus (INPH) is characterized by a classic triad of symptoms including dementia, urinary incontinence, and gait disturbance. INPH is clinically diagnosed in most patients during the sixth or seventh decade of life. Many older adults are incorrectly diagnosed with disorders such as Parkinson's disease and dementia when their symptoms are actually caused by INPH. As life expectancy increases, the necessity of accurately diagnosing and effectively treating these affected individuals will become more challenging. The diagnosis of INPH is challenging and requires a combination of clinical signs and symptoms, radiographic findings, and diagnostic testing. The purpose of evaluation and testing of individuals with suspected INPH is to determine if surgical implantation of a ventriculoperitoneal (VP) shunt will be beneficial. VP shunting is now a common neurosurgical procedure, but it is one associated with risks and complications, which makes evaluation of \"shunt-responsiveness\" essential.
Journal Article
Older Americans and AIDS: Some Guidelines for Prevention
Social workers provide senior citizens with varied services in diverse settings and are in a position to assume leadership in slowing the spread of AIDS among this age group. Unfortunately older people often do not receive the knowledge needed to protect themselves against infection. Historically, older Americans have been largely ignored by HIV/AIDS prevention programs. The major risk behaviors among senior citizens include sexual activity without using condoms, alcohol and drug use, blood transfusions received before 1985, and misdiagnosed opportunistic illness such as Alzheimer's, Parkinson's, respiratory disease, and sexually transmitted diseases. The article discusses guidelines that can help social workers provide prevention education to older Americans. Social work's primary prevention AIDS education efforts can help older adults safely live out the rest of their lives secure in the understanding that they possess the knowledge to protect themselves from HIV/AIDS infection.
Journal Article
Outbreak of Pseudoinfection with Tsukamurella paurometabolum Traced to Laboratory Contamination: Efficacy of Joint Epidemiological and Laboratory Investigation
From January 1988 to May 1989, one hospital in South Carolina reported 12 isolates of Tsukamurella paurometabolum from 10 patients. There were no common risk factors among the patients. Case-control studies revealed that the positive specimens were significantly more likely to have been processed in the TB/fungal room, to have been tissue samples, and to have been handled by one technician. Typing on the basis of biochemical, antimicrobial resistance, Southern blot, and ribotype profiles showed that the isolates from the outbreak were essentially identical and that they were distinguishable from each of two isolates obtained after the outbreak and from two type strains. These findings support the hypothesis of a common-source outbreak of pseudoinfection. There are reasons to believe that T. paurometabolum is present both in the environment and as a culture contaminant more often than has been recognized and that it is very rarely the true cause of infection in humans. Typing results show differences between one type strain and all of the other isolates studied in terms of colonial morphology, biochemistry, antimicrobial susceptibility, and ribotyping; these differences suggest that the nomenclature of T. paurometabolum may require further clarification.
Journal Article