Diagnosis errors are frequent and important, but represent an underemphasized and understudied area of patient-safety. (1-8) This belief led us to embark on a 3-year project, funded by the Agency for Healthcare Research and Quality (AHRQ), to better understand where and how diagnosis fails and explore ways to target interventions that might prevent such failures. It is known that diagnosis errors are common and underemphasized, but they are also challenging ...
In health care organizations, the division of labor and a need for continuous, 24-hour treatment subjects patients to multiple transitions in care. These transitions, of "handovers" are potential points of failure that have seen very little study. We observed transitions of care in five hospital emergency departments as part of a larger study on safety in emergency care and found that in addition to many other differences in work patterns ...
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