Identifying diagnostic errors in the emergency department using trigger-based strategies.

Importance: Diagnostic errors represent a major patient safety concern, with the potential to significantly impact patient outcomes. To address this, various trigger-based strategies have been developed to identify diagnostic errors, aiming to enhance clinical decision-making and improve patient safety.

Objective: To evaluate the performance of three pre-established triggers (T) in the emergency department (ED) setting and assess their effectiveness in detecting diagnostic errors.

Design: Consecutive cohort, retrospective observational design.

Setting: Academic ED with 80 000 annual visits.

Participants: Adults and children presenting to a single ED in the USA between 1 May 2018 and 1 January 2020.

Intervention/outcomes: Electronic health records (EHRs) were retrieved and categorised into trigger-positive and trigger-negative cases using the following criteria: T1-unscheduled returnvisits to the ED with admission within 7-10 days of theinitial visit; T2-care escalation from the inpatient unitto the intensive care unit (ICU) within 6, 12 or 24 hoursof ED admission; and T3-all deaths in the ED or within24 hours of ED admission, excluding palliative care. A random sample of trigger-positive cases was reviewed using the SaferDx tool to determine the presence or absence of a diagnostic error.

Results: A total of 5791 trigger-positive and 118262 trigger-negative cases were identified. Among trigger-positive cases, 4159 (72%) were associated with T1, 1415 (24%) with T2, and 217 (4%) with T3. A preliminary chart review of 462 trigger-positive and 251 trigger-negative cases showed most were error-negative (279 and 217, respectively). Detailed reviews found 32 diagnostic errors among 183 trigger-positive cases, yielding PPVs of 5.4% (T1), 8.9% (T2), and 6.9% (T3). No errors were found in 34 reviewed trigger-negative cases, resulting in a 100% NPV. Sepsis was the most common diagnosis among error-positive cases (n=11, 34.4%). Those with non-specific chief complaints like altered mental status or shortness of breath had higher diagnostic error risk.

Conclusion and relevance: While previously proposed EHR-based triggers can identify some diagnostic errors, they are insufficient for detecting all cases. To improve error detection performance, we recommend exploring data-driven strategies, such as machine learning techniques, to more effectively identify underlying contributing factors to diagnostic errors and enhance detection accuracy in the ED.