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Diagnostic Error in Surgery and Surgical Services

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Surgical Patient Care

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Abstract

Surgical diagnostic errors are clinically and financially costly. Efforts to identify, monitor, and reduce the rates of these errors are urgently needed. Diagnostic error may involve various types of overlapping missed opportunities to make a correct and timely diagnosis; a diagnosis may be missed completely, the wrong one may be provided, or diagnosis may be delayed, all of which can lead to harm. Reliable surgical diagnosis and decision-making requires the full participation and engagement of many team members including the patient and their family. More research is needed to identify better metrics to measure and identify these errors. Hospitals and healthcare delivery systems need to significantly reenvision the surgical diagnostic process to achieve higher levels of reliability, patient centeredness, and better financial values.

“You’re on the Island of Conclusions.”

“But how did we get here?” asked Milo.

“You jumped, of course,” explained Canby. “That’s the way most everyone gets here. It’s really quite simple: every time you decide something without having a good reason, you jump to Conclusions whether you like it or not. It’s such an easy trip to make that I’ve been here hundreds of times.”

“But this is such an unpleasant looking place,” Milo remarked.

“Yes, that’s true,” admitted Canby; “it does look much better from a distance.”

—From The Phantom Tollbooth, by Norton Juster

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References

  1. Institute of Medicine. Improving diagnosis in health care. Washington, DC: National Academies Press; 2015.

    Google Scholar 

  2. Graber ML, Franklin N, Gordon RR. Diagnostic error in internal medicine. Arch Intern Med. 2005;165:1493–9.

    Article  PubMed  Google Scholar 

  3. Singh H. Helping health care organizations to define diagnostic errors as missed opportunities in diagnosis. Jt Comm J Qual Patient Saf. 2014;40(3):99–101.

    Article  PubMed  Google Scholar 

  4. Schiff GD, Hasan O, Kim S, Abrams R, Cosby K, Lambert B, et al. Diagnostic error in medicine—analysis of 583 physician-reported errors. Arch Intern Med. 2009;169(20):1881–7.

    Article  PubMed  Google Scholar 

  5. Newman-Toker D. A unified conceptual model for diagnostic errors: underdiagnosis, overdiagnosis, and misdiagnosis. Diagnosis. 2014;1(1):43–8.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Lilford R, Chilton P, Hemming K, Girling A, Taylor C, Barach P. Evaluating policy and service interventions: framework to guide selection and interpretation of study end points. Br Med J. 2010;341(Aug 27):C4413.

    Article  Google Scholar 

  7. Harris K, Strauss C, Eagle K, Hirsch AT, Isselbacher E, Tsai T, et al. Correlates of delayed recognition and treatment of acute type A aortic dissection. Circulation. 2011;124:1911–8.

    Article  PubMed  Google Scholar 

  8. Graber M. The incidence of diagnostic error. BMJ Qual Saf. 2013;22(Part 2):ii21–7.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Leape L, Berwick D, Bates D. Counting deaths from medical errors. JAMA. 2002;288(19):2405.

    Article  Google Scholar 

  10. Gawande A. Complications: a surgeon’s notes on an imperfect science. New York, NY: Picador; 2002.

    Google Scholar 

  11. CRICO Strategies. Annual Benchmarking report—malpractice risks in the diagnostic process. 2014. http://www.rmfstrategies.com/Products-and-Services/Comparative-Data/Annual-Benchmark-Reports

  12. Troxel D. Diagnostic error in medical practice by specialty. The Doctor’s Advocate. 2014;Third Quarter. http://www.thedoctors.com/KnowledgeCenter/Publications/

  13. Graber M, Trowbridge R, Myers J, Umscheid C, Strull W, Kanter M. The next organizational challenge: finding and addressing diagnostic error. Jt Comm J Qual Patient Saf. 2014;40(3):102–10.

    Article  PubMed  Google Scholar 

  14. Graber M, Wachter R, Cassel C. Bringing diagnosis into the quality and safety equations. JAMA. 2012;308(12):1211–2.

    Article  CAS  PubMed  Google Scholar 

  15. Graber M. Diagnostic errors in medicine: a case of neglect. Jt Comm J Qual Patient Saf. 2005;31(2):106–13.

    Article  PubMed  Google Scholar 

  16. Singh H, Graber M. Improving diagnosis in health care—the next imperative for patient safety. N Engl J Med. 2015;373(26):2493–5.

    Article  PubMed  Google Scholar 

  17. Singh H, Meyer A, Thomas E. The frequency of diagnostic errors in outpatient care: estimations from three large observational studies involving US adult populations. BMJ Qual Saf. 2014;23(9):727–31. doi:10.1136/bmjqs-2013-002627.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Shojania K, Burton E, McDonald K, et al. The autopsy as an outcome and performance measure: evidence report/technology assessment #58. AHRQ Publication No 03-E002. 2002.

    Google Scholar 

  19. Winters B, Custer J, Galvagno S, Colantuoni E, Kapoor S, Lee H, et al. Diagnostic errors in the intensive care unit: a systematic review of autopsy studies. BMJ Qual Saf. 2012;21:894–902.

    Article  PubMed  Google Scholar 

  20. Meyer A, Singh H, Graber M. Evaluation of outcomes from a national patient-initiated second-opinion program. Am J Med. 2015;128(10):e25–33.

    Article  Google Scholar 

  21. Graff L, Russell J, Seashore J, Tate J, Elwell A, Prete M, et al. False-negative and false-positive errors in abdominal pain evaluation: failure to diagnose acute appendicitis and unnecessary surgery. Acad Emerg Med. 2000;7(11):1244–55.

    Article  CAS  PubMed  Google Scholar 

  22. Kowalski R, Claasen J, Kreiter K, et al. Initial misdiagnosis and outcome after subarrachnoid hemorrhage. JAMA. 2004;291:866–9.

    Article  CAS  PubMed  Google Scholar 

  23. Edlow JA. Diagnosis of subarachnoid hemorrhage. Neurocrit Care. 2005;2(2):99–109.

    Article  PubMed  Google Scholar 

  24. von Kodolitsch Y, Schwartz AG, Nienaber CA. Clinical prediction of acute aortic dissection. Arch Intern Med. 2000;160:2977–82.

    Article  Google Scholar 

  25. Lederle F, Parenti C, Chute E. Ruptured abdominal aortic aneurysm: the internist as diagnostician. Am J Med. 1994;96:163–7.

    Article  CAS  PubMed  Google Scholar 

  26. Mikulin T, Hardcastel J. Gastric cancer—delay in diagnosis and its causes. EurJ Cancer Clin Oncol. 1987;23:1683–90.

    Article  CAS  Google Scholar 

  27. Schnetler J. Oral cancer diagnosis and delays in referral. Br J Oral Maxillfac Surg. 1992;30:210–3.

    Article  CAS  Google Scholar 

  28. Beam C, Layde P, Sullivan D. Variability in the interpretation of screening mammograms by US radiologists. Findings from a national sample. Arch Intern Med. 1996;156(2):209–13.

    Article  CAS  PubMed  Google Scholar 

  29. Burton EC, Troxclair DA, Newman III WP. Autopsy diagnoses of malignant neoplasms: how often are clinical diagnoses incorrect? JAMA. 1998;280(14):1245–8.

    Article  CAS  PubMed  Google Scholar 

  30. Burgess C, Ramirez A, Richards M, et al. Who and what influences delayed presentation in breast cancer? Br J Cancer. 1998;77:1343–8.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  31. Kantola S, Jokinen K, Hyrnkangas K, et al. Detection of tongue cancer in primary care. Br J Gen Pract. 2001;51:106–11.

    CAS  PubMed  PubMed Central  Google Scholar 

  32. Levack P, Graham J, Collie D, et al. Don’t wait for a sensory level—listen to the symptoms; a prospective audit of the delays in diagnosis of malignant spinal cord compression. Clin Oncol (R Coll Radiol). 2002;14:472–80.

    Article  CAS  Google Scholar 

  33. Nakleh R. Diagnostic error in surgical pathology. Diagn Histopathol. 2013;19(12):433–7.

    Article  Google Scholar 

  34. Raab S, Nakhleh R, Ruby S. Patient safety in anatomic pathology: measuring discrepancy frequencies and causes. Arch Pathol Lab Med. 2005;129:459–66.

    PubMed  Google Scholar 

  35. Lipsitt DR. Factitious disorder and Munchausen syndrome. 2009.

    Google Scholar 

  36. Croskerry P. A universal model of diagnostic reasoning. Acad Med. 2009;84(8):1022–8.

    Article  PubMed  Google Scholar 

  37. Schulz C. On being wrong. TED Talk. https://www.ted.com/talks/kathryn_schulz_on_being_wrong?language=en

  38. Podbregar M, Voga G, Krivec B, Skale R, Pareznik R, Gabrscek L. Should we confirm our clinical diagnostic certainty by autopsies? Intensive Care Med. 2001;27:1750–5.

    Article  CAS  PubMed  Google Scholar 

  39. Friedman C, Gatti G, Franz T, Murphy G, Wolf F, Heckerling P, et al. Do physicians know their diagnoses are correct? Implications for decision support and error reduction. J Gen Intern Med. 2005;20(4):334–9.

    Article  PubMed  PubMed Central  Google Scholar 

  40. Meyer A, Payne V, Meeks D, Rao R, Singh H. Physicians’ diagnostic accuracy, confidence, and resource requests. JAMA Intern Med. 2013;173(21):1952–8.

    Article  PubMed  Google Scholar 

  41. Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med. 2003;78(8):775–80.

    Article  PubMed  Google Scholar 

  42. O’leary J, Barach P, Shorten G. Improving clinical performance using rehearsal and warm up. A systematic review of randomized trial and observational studies. Acad Med. 2014;89(10):1416–22.

    Google Scholar 

  43. Barach P, Cosman P. Teams, team training, and the role of simulation. In: Barach P, Jacobs J, Laussen P, Lipshultz S, editors. Outcomes analysis, quality improvement, and patient safety for pediatric and congenital cardiac disease. New York, NY: Springer Books; 2014. ISBN 978-1-4471-4618-6.

    Google Scholar 

  44. Berner E, Graber M. Overconfidence as a cause of diagnostic error in medicine. Am J Med. 2008;121(5 Suppl):S2–23.

    Article  PubMed  Google Scholar 

  45. Plebani M, Laposata M, Lundberg GD. The Brain-to-Brain loop concept for laboratory testing 40 years after its introduction. Am J Clin Pathol. 2011;136(6):829–33.

    Article  PubMed  Google Scholar 

  46. Meier F, Varney R, Zarbo R. Study of amended reports to evaluate and improve surgical pathology processess. Adv Anat Pathol. 2011;18(5):406–13.

    Article  PubMed  Google Scholar 

  47. Elmore J, Nelson H, Pepe M, Longton G, Tosteson A, Geller B, et al. Variability in pathologists interpretations of individual breast biopsy slides: a population perspective. Ann Intern Med. 2016;164:649–55.

    Article  PubMed  PubMed Central  Google Scholar 

  48. Raab SSGD. Quality in cancer diagnosis. CA Cancer J Clin. 2010;60(3):27.

    Article  Google Scholar 

  49. Nakleh R, Nose V, Colasacco C, Fatheree L, Lillemoe T, McCrory F, et al. Interpretive diagnostic error reduction in surgical pathology and cytology: guideline from the College of American Pathologists Pathology and Laboratory Quality Center and the Association of Directors of Anatomic and Surgical Pathology. Arch Pathol Lab Med. 2016;140(1):29–40.

    Article  Google Scholar 

  50. Lippi G, Guidi GS, Plebani M. One hundred years of laboratory testing and patient safety. Am J Clin Pathol. 2007;45(6):2.

    CAS  Google Scholar 

  51. Plebani M. Exploring the iceberg of errors in laboratory medicine. Clin Chim Acta. 2009;404(1):16–23.

    Article  CAS  PubMed  Google Scholar 

  52. Singh H, Thomas EJ, Mani S, Sittig D, Arora H, Espadas D, et al. Timely follow-up of abnormal diagnostic imaging test results in an outpatient setting: are electronic medical records achieving their potential? Arch Intern Med. 2009;169(17):1578–86.

    Article  PubMed  PubMed Central  Google Scholar 

  53. Al-Magrabi J, Savadi H. The importance of second opinions in surgical pathology referral material of lymphoma. Saudi Med J. 2012;33(4):399–405.

    Google Scholar 

  54. Lueck N, Jensen C, Cohen M, Weydert J. Mandatory second opinion in cytopathology. Cancer. 2009;117(2):82–91.

    PubMed  Google Scholar 

  55. Manion E, Cohen MB, Weydert J. Mandatory second opinion in surgical pathology referral material: clinical consequences of major disagreements. Am J Surg Pathol. 2008;32(5):732–7.

    Article  PubMed  Google Scholar 

  56. Swapp R, Aubry M, Salomao D, Cheville J. Outside case review of surgical pathology for referred patients. Arch Pathol Lab Med. 2013;137(Feb):233–40.

    Article  PubMed  Google Scholar 

  57. Srigley J, Fletcher G, Boag A, Joshi S, Khalifa M, Mullen B, et al. Best practices for oncologic pathology secondary review: methods and overview. 2014. https://www.cancercare.on.ca

  58. Causer J, Barach P, Williams M. Expertise in medicine: using the expert performance approach to improve simulation training. Med Educ. 2014;48:115–23.

    Article  PubMed  Google Scholar 

  59. Chi MT, Glaser R, Farr MJ. The nature of expertise. Hillsdale, NJ: Lawrence Erlbaum Associates; 1988.

    Google Scholar 

  60. Hoffman RR, Shadbolt NR, Burton AM, Klein G. Eliciting knowledge from experts: a methodological analysis. Organ Behav Hum Decis Process. 1995;62:129–58.

    Article  Google Scholar 

  61. Lesgold A, Rubinson H, Feltovich P, Glaser R, Klopfer D, Wang Y. Expertise in a complex skill: diagnosing X-ray pictures. In: Chi M, Glaser R, Farr MJ, editors. The nature of expertise. Hillsdale, NJ: Erlbaum; 1988. p. 311–42.

    Google Scholar 

  62. Graber M, Kissam S, Payne V, Meyer A, Sorensen A, Lenfestey N, et al. Cognitive interventions to reduce diagnostic error: a narrative review. BMJ Qual Saf. 2012;21:535–57.

    Article  PubMed  Google Scholar 

  63. McDonald K, Matesic B, Contopoulos-Iannidis D, Lonhart J, Schmidt E, Pineda N, et al. Patient safety strategies targeted at diagnostic errors—a systematic review. Ann Intern Med. 2013;158(5):381–9.

    Article  PubMed  Google Scholar 

  64. Croskerry P, Singhal G, Mamede S. Cognitive debiasing 2: impediments to and strategies for change. BMJ Qual Saf. 2013;22ii:65–72.

    Article  Google Scholar 

  65. Croskerry P, Singhal G, Mamede S. Cognitive debiasing 1: origins of bias and theory of debiasing. BMJ Qual Saf. 2013;22 Suppl 2:ii58–64.

    Article  PubMed  PubMed Central  Google Scholar 

  66. Mamede S, Schmidt H, Rikers R, Custers E, Splinter T, van Saase J. Conscious thought beats deliberation without attention in diagnostic decision making: at least when you are an expert. Psychol Res. 2010;74:586–92.

    Article  PubMed  PubMed Central  Google Scholar 

  67. Singh H, Traber D, Meyer A, Forjuoh S, Reis M, Thomas E. Types and origins of diagnostic errors in primary care settings. JAMA Intern Med. 2013;173(6):418–25.

    Article  PubMed  PubMed Central  Google Scholar 

  68. Graber M. Minimizing diagnostic error: 10 things you could do tomorrow. Inside Medical Liability, First Quarter. 2014.

    Google Scholar 

  69. Hoyland S, Aase K, Holland J. Exploring varieties of knowledge in safe work practices—an ethnographic study of surgical teams. Patient Saf Surg. 2011;5:21.

    Article  PubMed  PubMed Central  Google Scholar 

  70. Barach P. Team based risk modification program to make health care safer. Theor Iss Ergon Sci. 2007;8:481–94.

    Google Scholar 

  71. Hanson C, Barach P. Improving cardiac care quality and safety through partnerships with patients and their families. Prog Pediatr Cardiol. 2012;33:73–9.

    Article  Google Scholar 

  72. McDonald K, Bryce C, Graber M. The patient is in: patient involvement strategies for diagnostic error mitigation. BMJ Qual Saf. 2013;22(Part 2):30–6.

    Google Scholar 

  73. Mazzocco K, Petiti D, Fong K, Bonacum D, Brookey J, Graham R, et al. Surgical team behaviors and patient outcomes. Am J Surg. 2009;197(5):678–85.

    Article  PubMed  Google Scholar 

  74. Vashdi D, Bamberger P, Frez M. Can surgical teams ever learn? The role of complexity and transivity in action team learning. Acad Manage J. 2013;56(4):945–71.

    Article  Google Scholar 

  75. Hu Y, Parker S, Lipsitz S, Arriaga A, Peyre S, Corso K, et al. Surgeons’ leadership styles and team behavior in the operating room. J Am Coll Surg. 2016;222(1):41–51.

    Article  PubMed  Google Scholar 

  76. Edmondson A. Psychological safety and learning behavior in work teams. Admin Sci Quart. 1999;44(2):350–83.

    Article  Google Scholar 

  77. Winlaw D, Large M, Barach P. Leadership, surgeon well-being and other non-technical aspects of pediatric cardiac surgery. Prog Pediatr Cardiol. 2011;2011(32):129–33.

    Google Scholar 

  78. Barach P. The role of team training and simulation in advanced trauma care. In: Smith C, editor. Trauma care. Cambridge: Cambridge University Press; 2008. p. 579–91. ISBN 0521870585.

    Google Scholar 

  79. Baker D, Salas E, Barach P, Battles J, King H. The relation between teamwork and patient safety. In: Carayon P, editor. Handbook of human factors and ergonomics in health care and patient safety. Hillsdale, NJ: Lawrence Erlbaum Associates; 2006. p. 259–71.

    Google Scholar 

  80. Salas E, Baker D, King H, Battles J, Barach P. On teams, organizations and safety. Jt Comm J Qual Patient Saf. 2006;32:109–12.

    Article  Google Scholar 

  81. Bognar A, Barach P, Johnson J, Duncan R, Woods D, Holl J, Birnbach D, Bacha E. Errors and the burden of errors: attitudes, perceptions and the culture of safety in pediatric cardiac surgical teams. Ann Thorac Surg. 2008;85(4):1374–81.

    Article  PubMed  Google Scholar 

  82. Schraagen J, Schouten A, Smit M, van der Beck D, Van de Ven J, Barach P. Improving methods for studying teamwork in cardiac surgery. Qual Saf Health Care. 2010;19:1–6.

    Article  Google Scholar 

  83. Flin R, Patey R, Glavin R, Maran N. Anaesthetists’ non-technical skills. Br J Anaesth. 2010;105(1):38–44.

    Article  CAS  PubMed  Google Scholar 

  84. Bogner A, Barach P, Johnson J, Duncan R, Woods D, Holl J, et al. Errors and the burden of errors: attitudes, perceptions and culture of safety in pediatric cardiac surgical teams. Ann Thorac Surg. 2008;85(4):1374–81.

    Article  Google Scholar 

  85. Schraagen J, Schouten A, Smit M, van der Beck D, Van de Ven J, Barach P. A prospective study of paediatric cardiac surgery microsystems; assessing the relationships between non-routine events, teamwork, and patient outcomes. BMJ Qual Saf. 2011;20(7):599–603. doi:10.1136/bmjqs.2010.048983.

    Article  PubMed  Google Scholar 

  86. Payne V, Singh H, Meyer A, Levey L, Harrison D, Graber M. Patient-initiated second opinions: systematic review of characteristics and impact on diagnosis, treatment, and satisfaction. Mayo Clin Proc. 2014;89(5):687–96.

    Article  PubMed  Google Scholar 

  87. Newman E, Guest A, Helvie M, Roubidoux A, Chang A, Kleer K, et al. Changes in surgical management resulting from case review at a breast cancer multidisciplinary tumor board. Cancer. 2006;107:2346–51.

    Article  PubMed  Google Scholar 

  88. Grafe WR, McSherry CK, Finkel ML, McCarthy EG. The elective surgery second opinion program. Ann Surg. 1978;188(3):323–30.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  89. Keijers G, Campbell D, Hooper J, et al. A prospective evaluation of missed injuries in trauma patients before and after formalising the trauma tertiary survey. World J Surg. 2014;38(1):222–32.

    Article  Google Scholar 

  90. Resler J, Hackworth J, Mayo E, Rouse T. Detection of missed injuries in a pediatric trauma center with the addition of acute care pediatric nurse practitioners. J Trauma Nurs. 2014;21:272–5.

    Article  PubMed  Google Scholar 

  91. Ramnarayan P, Cronje N, Brown R, Negus R, Coode B, Moss P, et al. Validation of a diagnostic reminder system in emergency medicine: a multi-centre study. Emerg Med J. 2007;24(9):619–24.

    Article  PubMed  PubMed Central  Google Scholar 

  92. Ramnarayan P, Roberts GC, Coren M, Nanduri V, Tomlinson A, Taylor PM, et al. Assessment of the potential impact of a reminder system on the reduction of diagnostic errors: a quasi-experimental study. BMC Med Inform Decis Mak. 2006;6:22.

    Article  PubMed  PubMed Central  Google Scholar 

  93. Bond W, Schwartz L, Weaver K, Levick D, Giuliano M, Graber M. Differential diagnosis generators: an evaluation of currently available computer programs. J Gen Intern Med. 2011;27(2):213–9.

    Article  PubMed Central  Google Scholar 

  94. Berner ES. Clinical decision support systems. New York: Springer; 2007.

    Book  Google Scholar 

  95. Urbach D, Govindarajan A, Saskin R, Wilton A, Baxter N. Introduction of surgical safety checklists in Ontario, Canada. N Engl J Med. 2014;370(11):1029–38.

    Article  CAS  PubMed  Google Scholar 

  96. Institute of Medicine, editor. To err is human, building a safer health system. Washington, DC: National Academy Press; 1999.

    Google Scholar 

  97. Singh H, Graber M, Kissam S, et al. System-related interventions to reduce diagnostic errors: a narrative review. BMJ Qual Saf. 2012;21:160–70.

    Article  PubMed  Google Scholar 

  98. Barach P, Johnson J, Ahmed A, Galvan C, Bogner A, Duncan R, et al. Intraoperative adverse events and their impact on pediatric cardiac surgery: a prospective observational study. J Thorac Cardiovasc Surg. 2008;136(6):1422–8.

    Article  PubMed  Google Scholar 

  99. Seiden S, Barach P. Wrong-side, wrong procedure, and wrong patient adverse events: are they preventable? Arch Surg. 2006;141:1–9.

    Article  Google Scholar 

  100. Sharit J, McCane L, Thevenin D, Barach P. Examining links between sign-out reporting during shift changeovers and patient management risks. Risk Anal. 2008;28(4):983–1001.

    Article  Google Scholar 

  101. Upadhyay D, Sittig D, Singh H. Ebola US Patient Zero: lessons on misdiagnosis and effective use of electronic health records. Diagnosis. 2014;1(4):283. doi:10.1515/dx-2014-0064.

    Article  PubMed  PubMed Central  Google Scholar 

  102. Partnership for Health IT Patient Safety. Health IT safe practices: toolkit for the safe use of copy and paste. Plymouth Meeting: ECRI Institute; 2016.

    Google Scholar 

  103. El-Kareh R, Hasan O, Schiff G. Use of health information technology to reduce diagnostic error. BMJ Qual Saf. 2013;22ii:40–4.

    Article  Google Scholar 

  104. Schiff G. Clinical documentation and patient safety—the next frontier for better diagnosis and treatment. ONC Health IT Safety Webinar Series, July 30, 2015. Available at: wwwhealthitsafetyorg

    Google Scholar 

  105. Healey AN, Sevdalis N, Vincent CA. Measuring intra-operative interference from distraction and interruption observed in the operating theatre. Ergonomics. 2006;49(5–6):589–604.

    Article  CAS  PubMed  Google Scholar 

  106. Hesselink G, Vernooij-Dassen M, Pijnenborg L, Barach P, Gademan P, Dudzik-Urbaniak E, Flink M, Orrego C, Toccafondi G, Johnson JK, Schoonhoven L, Wollersheim H. Organizational culture: an important context for addressing and improving hospital to community patient discharge. Med Care. 2013;51(1):90–8. doi:10.1097/MLR.0b013e31827632ec.

  107. Vohra P, Daugherty C, Mohr J, Wen M, Barach P. Housestaff and medical student attitudes towards adverse medical events. Jt Comm J Qual Patient Saf. 2007;33:467–76.

    Article  Google Scholar 

  108. Mayer D, Gunderson A, Klemen D, Barach P. Designing a patient safety undergraduate medical curriculum: the Telluride Interdisciplinary Invitational Roundtable experience. Teach Learn Med. 2009;21(1):52–8.

    Article  PubMed  Google Scholar 

  109. Greene J, Hibbard J, Sacks R, Overton V, Parrotta C. When patient activation levels change, health outcomes and costs change, too. Health Aff. 2014;34(3):431–7.

    Article  Google Scholar 

  110. Arteburn D, Wellman R, WEstbrook E, Rutter C, Ross T, McColloch D, et al. Introducing decision aids at group health was linked to sharply lower hip and knee surgery rates and costs. Health Aff. 2012;31(9):2094–104.

    Article  Google Scholar 

  111. Krajewski S, Brown J, Phang P, Raval M, Brown C. Impact of computed tomography of the abdomen on clinical outcomes in patients with acute right lower quadrant pain: a meta-analysis. Can J Surg. 2011;54(1):45–53.

    Article  Google Scholar 

  112. Verghese A. In praise of the physical examination. BMJ. 2009;339:1385–7.

    Article  Google Scholar 

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Authors and Affiliations

  1. Society to Improve Diagnosis in Medicine, RTI International, 5 Hitching Post, Plymouth, MA, 02360, USA

    Mark L. Graber MD

  2. Department of Surgery, Ascension Saint Agnes Hospital, Armstrong Institute for Patient Safety & Quality, Johns Hopkins University School of Medicine Baltimore, Baltimore, MD, USA

    Juan A. Sanchez MD, MPA

  3. Children’s Cardiomyopathy Foundation and Kyle John Rymiszewski Research Scholar, Children’s Hospital of Michigan, Wayne State University School of Medicine, 5057 Woodward Avenue, Suite 13001, Detroit, MI, 48202, USA

    Paul Barach BSc, MD, MPH, Maj (ret.) (Clinical Professor)

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  1. Mark L. Graber MD
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  2. Juan A. Sanchez MD, MPA
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  3. Paul Barach BSc, MD, MPH, Maj (ret.)
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Correspondence to Mark L. Graber MD .

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Editors and Affiliations

  1. Department of Surgery Ascension Saint Agnes Hospital Armstrong Institute for Patient Safety & Quality, Johns Hopkins University School of Medicine, Baltimore, MD, USA

    Juan A. Sanchez

  2. Children’s Cardiomyopathy Foundation and Kyle John Rymiszewski Research Scholar, Children’s Hospital of Michigan, Wayne State University School of Medicine, Detroit, MI, USA

    Paul Barach

  3. Department of Surgery Center for Healthcare Studies Institute for Public Health and Medicine Feinberg School of Medicine, Northwestern University, Chicago, IL, USA

    Julie K. Johnson

  4. Division of Cardiovascular Surgery Johns Hopkins All Children’s Heart Institute Johns Hopkins All Children’s Hospital, Johns Hopkins University, Saint Petersburg, FL, USA

    Jeffrey P. Jacobs

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Graber, M.L., Sanchez, J.A., Barach, P. (2017). Diagnostic Error in Surgery and Surgical Services. In: Sanchez, J., Barach, P., Johnson, J., Jacobs, J. (eds) Surgical Patient Care. Springer, Cham. https://doi.org/10.1007/978-3-319-44010-1_25

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