Implementation of Electronic Triggers to Identify Diagnostic Errors in Emergency Departments

Importance: Missed diagnosis can lead to preventable patient harm. Objective: To develop and implement a portfolio of electronic triggers (e-triggers) and examine their performance for identifying missed opportunities in diagnosis (MODs) in emergency departments (EDs). Design, Setting, and Participants: In this retrospective medical record review study of ED visits at 1321 Veterans Affairs health care sites, rules-based e-triggers were developed and implemented using a national electronic health record repository. These e-triggers targeted 6 high-risk presentations for MODs in treat-and-release ED visits. A high-risk stroke e-trigger was applied to treat-and-release ED visits from January 1, 2016, to December 31, 2020. A symptom-disease dyad e-trigger was applied to visits from January 1, 2018, to December 31, 2019. High-risk abdominal pain, unexpected ED return, unexpected hospital return, and test result e-triggers were applied to visits from January 1, 2019, to December 31, 2019. At least 100 randomly selected flagged records were reviewed by physician reviewers for each e-trigger. Data were analyzed between January 2024 and April 2024. Exposures: Treat-and-release ED visits involving high-risk stroke, symptom-disease dyads, high-risk abdominal pain, unexpected ED return, unexpected hospital return, and abnormal test results not followed up after initial ED visit. Main Outcomes and Measures: Trained physician reviewers evaluated the presence/absence of MODs at ED visits and recorded data on patient and clinician characteristics, types of diagnostic process breakdowns, and potential harm from MODs. Results: The high-risk stroke e-trigger was applied to 8 792 672 treat-and-release ED visits (4 967 283 unique patients); the symptom-disease dyad e-trigger was applied to 3 692 454 visits (2 070 979 patients); and high-risk abdominal pain, unexpected ED return, unexpected hospital return, and test result e-triggers were applied to 1 845 905 visits (1 032 969 patients), overall identifying 203, 1981, 170, 116 785, 14 879, and 2090 trigger-positive records, respectively. Review of 625 randomly selected patient records (mean SD age, 62.5 15.2 years; 553 88.5% male) showed the following MOD counts and positive predictive values (PPVs) within each category: 47 MODs (PPV, 47.0%) for stroke, 31 MODs (PPV, 25.8%) for abdominal pain, 11 MODs (PPV, 11.0%) for ED returns, 23 MODs (PPV, 23.0%) for hospital returns, 18 MODs (PPV, 18.0%) for symptom-disease dyads, and 55 MODs (PPV, 52.4%) for test results. Patients with MODs were slightly older than those without (mean SD age, 65.6 14.5 vs 61.2 15.3 years; P < .001). Reviewer agreement was favorable (range, 72%-100%). In 108 of 130 MODs (83.1%; excluding MODs related to the test result e-trigger), the most common diagnostic process breakdown involved the patient-clinician encounter. In 185 total MODs, 20 patients experienced severe harm (10.8%), and 54 patients experienced moderate harm (29.2%). Conclusions and Relevance: In this retrospective medical record review study, rules-based e-triggers were useful for post hoc detection of MODs in ED visits. Interventions to target ED work system factors are urgently needed to support patient-clinician encounters and minimize harm from diagnostic errors.