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psnet.ahrq.gov/issue/incidence-duration-and-risk-factors-associated-delayed-and-missed-diagnostic-opportunities
May 19, 2021 - patients experienced at least one missed opportunity for a diagnosis in the year before they were finally diagnosed
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psnet.ahrq.gov/issue/injuries-and-after-diagnosis-cancer-nationwide-register-based-study
May 25, 2022 - other types of injuries as well, corroborating prior studies that have found that patients recently diagnosed
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psnet.ahrq.gov/issue/readmission-after-delayed-diagnosis-surgical-site-infection-focus-prevention-using-american
September 22, 2021 - Researchers found that nearly 50% of patients were diagnosed following hospital discharge, and many of
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psnet.ahrq.gov/issue/covid-19-dominates-annual-list-patient-safety-concerns
May 26, 2021 - Yet it often takes a decade to get diagnosed.
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psnet.ahrq.gov/issue/survey-ohio-regulator-shows-stress-fatigue-among-pharmacists-chain-stores
November 09, 2022 - Yet it often takes a decade to get diagnosed.
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psnet.ahrq.gov/issue/walgreens-will-stop-judging-its-pharmacy-staffers-how-fast-they-work
May 05, 2021 - Yet it often takes a decade to get diagnosed.
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psnet.ahrq.gov/issue/unlocking-solutions-imaging-working-together-learn-failings-nhs
October 07, 2020 - October 5, 2022
Multiple Failures in Test Results Follow-up for a Patient Diagnosed with
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psnet.ahrq.gov/issue/new-covid-boosters-look-lot-old-ones-doctors-worry-could-lead-errors
April 26, 2023 - Yet it often takes a decade to get diagnosed.
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psnet.ahrq.gov/issue/ongoing-nightmare-people-obesity-face-major-obstacles-when-seeking-medical-care
November 09, 2022 - Yet it often takes a decade to get diagnosed.
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psnet.ahrq.gov/issue/she-was-headed-locked-psych-ward-then-er-doctor-made-startling-discovery
March 03, 2021 - Yet it often takes a decade to get diagnosed.
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psnet.ahrq.gov/issue/surgical-robot-examined-injuries
April 27, 2016 - Yet it often takes a decade to get diagnosed.
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psnet.ahrq.gov/issue/how-major-public-hospital-protecting-doctors-silencing-patients-who-accuse-them
January 24, 2024 - Yet it often takes a decade to get diagnosed.
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psnet.ahrq.gov/issue/underdiagnosis-dementia-observational-study-patterns-diagnosis-and-awareness-us-older-adults
October 14, 2016 - Many patients who were diagnosed with dementia were not aware of their diagnosis.
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psnet.ahrq.gov/issue/process-care-failures-breast-cancer-diagnosis
January 06, 2017 - This retrospective chart review analyzed cases of recently diagnosed breast cancer to identify patient
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psnet.ahrq.gov/issue/detection-postoperative-respiratory-failure-how-predictive-agency-healthcare-research-and
January 13, 2010 - Patient Safety Indicator for postoperative respiratory failure accurately identified cases of clinically diagnosed
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psnet.ahrq.gov/issue/current-state-diagnostic-safety-implications-research-practice-and-policy
August 07, 2024 - August 16, 2023
Multiple Failures in Test Results Follow-up for a Patient Diagnosed with
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psnet.ahrq.gov/issue/language-discordance-and-patient-care-babel
October 30, 2024 - 2024
"Black Women Should Not Die Giving Life": The lived experiences of Black women diagnosed
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psnet.ahrq.gov/issue/perruche-case-and-issue-compensation-consequences-medical-error
July 31, 2024 - March 17, 2021
Reevaluation of diagnosis in adults with physician-diagnosed asthma.
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psnet.ahrq.gov/sites/default/files/2021-09/spotlight_missed_sea_09.17.2021_-_final.pdf
January 01, 2021 - – He was diagnosed with viral meningitis and sent home with antiemetics and
long-acting oral morphine … diagnosis is delayed have the worst
outcomes.
16
Risk Factors
17
Risk Factors
• 98% of patients diagnosed … – Meningitis is the most common incorrect admission diagnosis in patients
who are ultimately diagnosed … to a capable facility with the necessary
resources
30
Management
31
Management (1)
• Once diagnosed … Approach to Improving Safety (6)
• Most patients with SEA are evaluated multiple times before being
diagnosed
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psnet.ahrq.gov/issue/broken-trust-making-patient-safety-more-just-promise
October 07, 2020 - 2024
"Black Women Should Not Die Giving Life": The lived experiences of Black women diagnosed