SHM Converge Scientific Abstract ePoster Gallery-Investigation of Causes of Diagnostic Errors in Pulmonary Embolism and Their Association to Medical Record Documentation

Investigation of Causes of Diagnostic Errors in Pulmonary Embolism and Their Association to Medical Record Documentation

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This single-center retrospective study examined diagnostic errors (DEs) in 120 new-onset acute pulmonary embolism (PE) cases seen from 2017 to 2022 at a Japanese hospital. Using the Revised Safer Dx instrument, two physicians identified DEs and analyzed causes with DEER, RDC, and GDP taxonomies.  <br /><br />The DE rate was 20.0% (24 cases). Among these, 66.7% were associated with patient harm, and 5 deaths occurred in the overall sample. In multivariable analysis, lower documentation of blood pressure and body temperature was significantly associated with DEs. Specifically, missing blood pressure and body temperature recordings were more common in DE cases than non-DE cases.  <br /><br />Root-cause analysis showed that most DEs involved failure to recognize key physical findings or failure to consider PE as a diagnosis. The study suggests this reflects overreliance on diagnostic testing and insufficient hands-on assessment (“hyposkillia”).  <br /><br />The authors note that careful recording of vital signs and physical findings may help clinicians identify critical disease earlier, support more accurate diagnosis, and prompt re-evaluation of the diagnostic process. They conclude that improving documentation of vital signs and physical exams could reduce diagnostic errors in PE.

Asset Subtitle

Hinata Nishimura

Meta Tag

Author List Hinata Nishimura, Taiju Miyagami, Toshio Naito

Category Research

Concept Pulmonary Embolism

Concept Diagnostic Error

Concept Vital Signs

Concept Physical Examination

Concept Documentation

Distinguished Non-Finalist

Presenter Organization Juntendo University Hospital

Presenting Author Hinata Nishimura

Track Patient Safety

Keywords

acute pulmonary embolism

diagnostic errors

retrospective study

vital signs documentation

blood pressure

body temperature

physical examination

diagnostic delay

patient harm

Japan hospital

Pulmonary Embolism

Diagnostic Error

Vital Signs

Physical Examination

Documentation