References
1. Soomers V, Hussin O, Young R, et al. The sarcoma diagnostic interval: a systematic review on length, contributing factors and patient outcomes. ESMO Open. 2020;5:e000592. doi:10.1136/ esmoopen-2019-000592. 2. CDC. US Cancer Statistics Data Brief. No 25. November 2021. https://www.cdc.gov/cancer/uscs/pdf/USCS-DataBrief-No25-November2021-h.pdf. 3. Newman-Toker DE, Wang Z, Zhu Z, et al. Rate od diagnostic errors and serious misdiagnosis-related harms for major vascular events, infections and cancers: toward a national incidence estimate using the “Big Three”. Diagnosis 2021;8:67-84. 4. Moffitt Cancer Center. 12 diseases that lung cancer is commonly misdiagnosed as. Accessed February 22, 2022. https://moffitt.org/cancers/lung- cancer/faqs/12-diseases-that-lung-cancer-is-commonly-misdiagnosed-as/. 5. del Ciello A, Franchi P, Contegiacomoc A, et al. Missed lung cancer: when, where, and why? Diagn Inter Radiol . 2017;23:118-126. 6. Wilner AN. Diagnostic errors in patients with neurologic symptoms. October 31, 2016. https://www.medscape.com/features/slideshow/diagnostic- errors/neurologic. 7. Solomon AJ, Bourdette DN, Cross AH, et al. The contemporary spectrum of multiple sclerosis misdiagnosis. Neurology . 2016;87;1393-1399. 8. CDC. Women and heart disease. Last reviewed: January 30, 2020. https://www.cdc.gov/heartdisease/women.htm. 9. American College of Cardiology. Taking the risks to heart: misdiagnosis of heart disease. February 20, 2017. https://www.acc.org/membership/ join-us/benefits/additional-member-only-benefits/acc-and-the-doctors-company/the-doctors-company-updates/2017/02/20/12/55/taking-the-risks- to-heart-misdiagnosis-of-heart disease#:~:text=In%20a%20study%20of%20closed,muscle%20damage%20from%20myocardial%20infarction. 10. Wong CW, Tafure J, Azam Z, et al. Misdiagnosis of heart failure: a systematic review of the literature. J Card Fail . 2021;27:925-933. 11. Yonash RA, Taylor MA. Wrong-side surgery in Pennsylvania during 2015-2019. Patient Safety . December 2020. https://patientsafetyj.com/index.php/ patientsaf/article/view/wrong-site-surgery. 12. Epstein N. A perspective on wrong level, wrong side, and wrong site spine surgery. Surg Neurol Int . 2021;12:286. doi:10.25259/SNI_402_2021 13. Weprin SA, Meyer D, Li R, et al. Incidence and OR tea awareness of “near-miss” and retained surgical sharps a national survey on United States operating rooms. Patient Safety Surg . 2021. https://doi.org/10.1186/s13037-021-00287-5 14. AHRQ. Surgical site infections. September 7, 2019. https://psnet.ahrq.gov/primer/surgical-site-infections. 15. Tomas ME, Getman D, Donskey CJ, Hecker MT. Overdiagnosis of urinary tract infection and underdiagnosis of sexually transmitted infection in adult women presenting to an emergency department. J Clin Microbiol . 2015;53;2686-2692. 16. Last reviewed: January 30, 2020.Hartley S, Valley S, Kuhn L, et al. Inappropriate testing for urinary tract infection in hospitalized patients: an opportunity for improvement . Infec Control Hosp Epidemiol. 2013;34:1204-12067. 17. Skove SL, Howard LE, Senechal J, et al. The misdiagnosis of interstitial cystitis/bladder pain syndrome in a VA population. Neurol Urodyn . 2019;38:1966- 1972. 18. Lynch NB, Xu L, Ambinder D, Malik RD. medical malpractice in stress incontinence management: a 30-year legal database review. Curr Urol. 2021;15:137- 142. 19. Accessed February 22, 2022. Zhang Y, Yuan S, Alshayyah RWA, et al. Spontaneous rupture of the urinary bladder: two case reports and review of the literature. Frontiers Surg . 2021. doi.org/10.3389/fsurg.2021.721705.
Table 1. 24 Analysis Questions from the Joint Commission Framework for Root Cause Analysis and Corrective Actions. 27
1. What was the intended process flow?
13. Did staff performance during the event meet expectations?
14. To what degree was all the necessary information available when needed?
2. Were there any steps in the process that did not occur as intended?
Accurate? Complete? Ambiguous?
3. What human factors were relevant to the outcome?
15. To what degree is communication among participants adequate? 16. Was this the appropriate physical environment for the processes being carried out?
4. How did the equipment performance affect the outcome?
5. What controllable environmental affected the outcome? 6. What uncontrollable external factors influenced the outcome? 7. Were there any other factors that directly influenced this outcome? 8. What are the other areas in the healthcare organization where this could happen? 9. Was staff properly qualified and currently competent for their responsibilities? 10. How did actual staffing compare with ideal level? 11. What is the plan for dealing with staffing contingencies?
17. What systems are in place to identify environmental risks?
18. What emergency and failure-mode responses have been planned and tested?
19. How does the organization’s culture support risk reduction?
20. What are the barriers to communication of potential risk factors?
21. How does leadership address the continuum of patient safety events, including close calls, adverse events, and unsafe, hazardous conditions?
22. How can orientation and in-service training be improved?
23. Was available technology used as intended?
12. Were such contingencies a factor in this event?
24. How might technology be introduced or redesigned to reduce risks in the future?
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