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Diagnostic error in a national incident reporting system in the UK

Lookup NU author(s): Professor Richard Thomson

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Abstract

Rationale, aims and objectives Diagnostic errors and delays carry potentially grave consequences for patients and feature prominently in studies of adverse events in health care. Diagnostic errors present a particular challenge for error/incident reporting systems because they involve clinical reasoning and are difficult to define precisely. The aim of the present study was to investigate what insights can be gained about diagnostic error from an incident reporting system. Methods Diagnostic errors reported to the UK's National Reporting and Learning System (NRLS) between November 2003 and October 2005 were investigated. We analysed reported level of harm to the patient and incident location and we compared diagnostic with non-diagnostic incidents. We also assessed the quality of reporting in a subset of reports associated with a patient's death. Results Of 316 589 incidents reported in the period under investigation, 1674 were diagnostic (0.5%). Diagnostic incidents were more likely than other incidents to be associated with moderate or severe harm, or a patient's death and were more likely to occur in a hospital emergency department than other incidents. Diagnostic incidents in emergency departments were more likely to be associated with greater harm than similar incidents in wards. Observed reporting quality (detail; clarity) was very variable. Conclusion These findings replicate findings from studies in emergency departments and suggest that reporting systems have a role to play in understanding diagnostic errors alongside other sources of error analysis. Accurate and complete reporting of adequate volume enhances the potential contribution of an incident reporting system to understanding diagnostic error.


Publication metadata

Author(s): Sevdalis N, Jacklin R, Arora S, Vincent CA, Thomson RG

Publication type: Article

Publication status: Published

Journal: Journal of Evaluation in Clinical Practice

Year: 2010

Volume: 16

Issue: 6

Pages: 1276-1281

Print publication date: 19/08/2010

ISSN (print): 1356-1294

ISSN (electronic): 1365-2753

Publisher: Wiley-Blackwell Publishing Ltd.

URL: http://dx.doi.org/10.1111/j.1365-2753.2009.01328.x

DOI: 10.1111/j.1365-2753.2009.01328.x


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