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Acil Serviste Atlanan Kırık ve Çıkıklarda Tanısal Zorluklar ve Hatalar

Year 2019, Volume: 9 Issue: 3, 379 - 386, 16.09.2019

İlker Çolak

https://doi.org/10.31832/smj.518911

Abstract



Eksik
veya hatalı tanı acil serviste sık karşılaşılan bir durumdur. Bir hastanın ilk
muayenesinde konulamayan tanı daha sonraki süreçte tespit edilirse, atlanmış
tanıdan bahsedilir.



Bu
çalışmanın amacı, tanı atlama ile ilgili literatürün gözden geçirilmesi ve
konuya yönelik öneriler sunmaktır. Acil servislerde daha fazla sayıda hastanın
daha tecrübeli doktorlar tarafından görülmesi ve tecrübesiz doktorların daha
iyi denetlenmesi, doktorların çalışma ortam ve sürelerinin, uyku düzenlerinin
optimal düzeyde olması sağlanmalıdır. Hataların azaltılması hedeflenerek eğitim
programlarının uygunluğu ve kalitesi arttırılmalıdır. Dikkatli, detaylı öykü ve
fizik muayene standardizasyonu sağlanmalıdır.




Keywords

acil servis atlanmış tanı ortopedi

References

  • Kaynaklar
  • 1. Thomson CB, Greaves I. Missed injury and the tertiary trauma survey. Injury 2008;39:107-14.
  • 2. Kachalia A, Gandhi TK, Puopolo AL, Yoon C, Thomas EJ, Griffey R, Studdert DM. Missed and delayed diagnoses in the emergency department: a study of closed malpractice claims from 4 liability insurers. Ann Emerg Med 2007; 49(2): 196-205.
  • 3. Pfeifer R, Pape HC. Missed injuries in trauma patients: a literature review. Patient Saf Surg 2008;2(1):20.
  • 4. Vincent CA. Research into medical accidents: a case of negligence? BMJ 1989; 299(6708):1150-3.
  • 5. Stanescu L, Talner LB, Mann FA. Diagnostic errors in polytrauma: a structured review of the recent literature. Emerg radiol 2006;12(3):119-23.
  • 6. Leea C, Bleetmanb A. Commonly missed injuries in the accident and emergency department. Trauma 2004;6:41-51.
  • 7. Enderson BL, Reath DB, Meadors J. The tertiary trauma survey: a prospective study of missed injury. J Trauma 1990;30(6):666-9.
  • 8. Houshian S, Larsen MS, Holm C. Missed injuries in a level Itrauma centre. J Trauma 2002;52(4):715-9.
  • 9. Chan RNW, Ainscow D, Sikorski JM. Diagnostic failures in themultiply injured. J Trauma 1980;20(8):684-7.
  • 10. Halsted MJ, Kumar H, Paquin JJ, Poe SA, Bean JA, Racadio JM, Strife JL, Donnelly LF. Diagnostic errors by radiology residents in interpreting pediatric radiographs in an emergency setting. Pediatr radiol 2004;34(4):331-6.
  • 11. Karcz A, Korn R, Burke MC, Caggiano R, Doyle MJ, Erdos MJ, Green ED, Williams K. Malpractice claims against emergency physicians in Massachusetts: 1975–1993. The Am J Em Med 1996;14(4):341-5.
  • 12. Guly HR. Diagnostic errors in an accident and emergency department. Em Med J 2001;18(4):263-9.
  • 13. Scalea TM, Phillips TF, Goldstein AS, Sclafani SJ, Duncan AO, Atweh NA, Shaftan GW. Injuries missed at operation: nemesis of the trauma surgeon. J trauma 1988; 28(7); 962-7.
  • 14. Gandhi TK, Kachalia A, Thomas EJ, Puopolo AL, Yoon C, Brennan TA, Studdert DM. Missed and delayed diagnoses in the ambulatory setting: a study of closed malpractice claims. Ann Intern Med 2006;145:488-96.
  • 15. Fordyce J, Blank FS, Pekow P, Smithline HA, Ritter G, Gehlbach S, Benjamin E, Henneman PL. Errors in a busy emergency department. Ann Emerg Med 2003;42:324-33.
  • 16. Kuhn G. Circadian rhythm, shift work, and emergency medicine.Ann Emerg Med 2001;37:88-98.
  • 17. Burç H, Baykal B, Atay T, Ünlü EN. Evaluation of common missed fractures and dislocations in orthopedics and traumatology. TOTBİD 2013;12(1):28-34.
  • 18. Lesar TS, Briceland LL, Delcoure K, Parmalee JC, Masta-Gornic V, Pohl H. Medication prescribing errors in a teaching hospital. Jama 1990; 263(17), 2329-2334.
  • 19. NG VCH, LAU FLA. retrospective review of patients with radiological missed fractures in an emergency department in Hong Kong. HKJM 2003;10:215-22.
  • 20. Aaland MO, Smith K. Delayed diagnosis in a rural trauma centre. Surgery 1996;120(4):774-9.
  • 21. Brooks A, Holroyd B, Riley B. Missed injury in major trauma patients. Injury 2004;35:407-10.
  • 22. Laasonen EM, Kivioja A. Delayed diagnosis of extremity injuries in patients with multiple injuries. J Trauma 1991;31(2):257-60.
  • 23. Vles WJ, Veen EJ, Roukema JA, et al. Consequences of delayed discharges in trauma patients: a prospective study. J Am Coll Surg 2003;197(4):596-602.
  • 24. Houshian S, Larsen MS, Holm C. Missed injuries in a level I trauma centre. J Trauma 2002;52(4):715-9.
  • 25. Janjua KJ, Sugrue M, Deane SA. Prospective evaluation of early missed injuries and the role of the tertiary trauma survey. J Trauma 1998;44(6):1000-7.
  • 26. Hoyt DB, Hollingsworth-Fridlund P, Winchell RJ, et al. Analysis of recurrent process errors leading to provider-related complications on an organized trauma service: directions for care improvement. J Trauma 1994;36(3):377-84.
  • 27. Pope JH, Aufderheide TP, Ruthazer R, et al. Missed diagnoses of acute cardiac ischemia in the emergency department. N Engl J Med 2000;342:1163-70.
  • 28. Espinosa JA, Nolan TW. Reducing errors made by emergencyphysicians in interpreting radiographs: longitudinal study. BMJ 2000;320:737-40.
  • 29. Pimentel L, McPherson SJ. Community-acquired pneumonia in theemergency department: a practical approach to diagnosis and management. Emerg Med Clin North Am 2003;21:395-420.
  • 30. Croskerry P. The cognitive imperative: thinking about how wethink. Acad Emerg Med 2000;7:1223-31.
  • 31. Wears RL, Perry SJ. Human factors and ergonomics in theemergency department. Ann Emerg Med 2002;40:206-12.
  • 32. White AA, Wright SW, Blanco R, et al. Cause-and-effect analysisof risk management files to assess patient care in the emergency department. Acad Emerg Med 2004;11:1035-41.
  • 33. McLauchlan CA, Jones K, Guly HR. Interpretation of trauma radiographs by junior doctors in accident and emergency departments: a cause for concern? J Accid Emerg Med 1997;14(5):295-8.
  • 34. Fraser J. The pre-registration year and the undergraduate curriculum. Proc R Soc Med 1973;66:29-30.
  • 35. Mizrahi T. Managing medical mistakes: ideology, insularity and accountability among internists-in-training. Soc sci med 1984;19(2)135-46.
  • 36. Olupeliyawa AM, Hughes C, Balasooriya CD. A review of the literature on teamwork competencies in healthcare practice and training: implications for undergraduate medical education. SEAJME 2009;3(2):61-72.
  • 37. Sexton JB, Thomas EJ, Helmreich RL. Error, stress, and teamwork in medicine and aviation: cross sectional surveys. BMJ 2000;320(7237):745-9.
  • 38. McKee M, Black N. Does the current use of junior doctors in the United Kingdom affect the quality of medical care? Soc sci med 1992;34(5):549-58.
  • 39. Enderson BL, Reath DB, Meadors J, Dallas W, DeBoo JM, Maull KI. The tertiary trauma survey: a prospective study of missed injury. J Trauma 1990;30(6):666-9.
  • 40. Toms AP. The war on terror and radiological error? Clinical radiology 2010;65(8):666-8.
  • 41. Waeckerle JF. A prospective study identifying the sensitivity of radiographic findings and the efficacy of clinical findings in carpal navicular fractures. Ann Emerg Med 1987;16:733-7.
  • 42. Cannon J, Silvestri S, Munro M. Imaging choices in occult hip fracture. J Emerg Med 2009;37:144-52.
  • 43. Livingston DH, Lavery RF, Passannante M, et al. Admission orobservation is not necessary after a negative abdominal computed tomographic scan in patients with suspected blunt abdominal trauma: results of a prospective, multi-institutional study. J Trauma. 1998;44:273-82.
  • 44. Brenner D, Elliston C. Estimated radiation risks potentiallyassociated with full-body CT screening. Radiology 2004;232:735-8.
  • 45. Snyder GE. Whole-body imaging in blunt multisystem trauma patients who were never examined. Ann em med 2008;52(2):101-3.
  • 46. Slovis TL. CT and computed radiography: the pictures are great, but is the radiation dose greater than required? Am J Radiol 2002;179:39-41.
  • 47. Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. N Engl J Med 2000;343:94-9.
  • 48. Richards JR, Derlet RW. Computed tomography for blunt abdominal trauma in the ED: a prospective study. Am J Emerg Med 1998;16:338-42.

Year 2019, Volume: 9 Issue: 3, 379 - 386, 16.09.2019

İlker Çolak

https://doi.org/10.31832/smj.518911

Abstract

References

  • Kaynaklar
  • 1. Thomson CB, Greaves I. Missed injury and the tertiary trauma survey. Injury 2008;39:107-14.
  • 2. Kachalia A, Gandhi TK, Puopolo AL, Yoon C, Thomas EJ, Griffey R, Studdert DM. Missed and delayed diagnoses in the emergency department: a study of closed malpractice claims from 4 liability insurers. Ann Emerg Med 2007; 49(2): 196-205.
  • 3. Pfeifer R, Pape HC. Missed injuries in trauma patients: a literature review. Patient Saf Surg 2008;2(1):20.
  • 4. Vincent CA. Research into medical accidents: a case of negligence? BMJ 1989; 299(6708):1150-3.
  • 5. Stanescu L, Talner LB, Mann FA. Diagnostic errors in polytrauma: a structured review of the recent literature. Emerg radiol 2006;12(3):119-23.
  • 6. Leea C, Bleetmanb A. Commonly missed injuries in the accident and emergency department. Trauma 2004;6:41-51.
  • 7. Enderson BL, Reath DB, Meadors J. The tertiary trauma survey: a prospective study of missed injury. J Trauma 1990;30(6):666-9.
  • 8. Houshian S, Larsen MS, Holm C. Missed injuries in a level Itrauma centre. J Trauma 2002;52(4):715-9.
  • 9. Chan RNW, Ainscow D, Sikorski JM. Diagnostic failures in themultiply injured. J Trauma 1980;20(8):684-7.
  • 10. Halsted MJ, Kumar H, Paquin JJ, Poe SA, Bean JA, Racadio JM, Strife JL, Donnelly LF. Diagnostic errors by radiology residents in interpreting pediatric radiographs in an emergency setting. Pediatr radiol 2004;34(4):331-6.
  • 11. Karcz A, Korn R, Burke MC, Caggiano R, Doyle MJ, Erdos MJ, Green ED, Williams K. Malpractice claims against emergency physicians in Massachusetts: 1975–1993. The Am J Em Med 1996;14(4):341-5.
  • 12. Guly HR. Diagnostic errors in an accident and emergency department. Em Med J 2001;18(4):263-9.
  • 13. Scalea TM, Phillips TF, Goldstein AS, Sclafani SJ, Duncan AO, Atweh NA, Shaftan GW. Injuries missed at operation: nemesis of the trauma surgeon. J trauma 1988; 28(7); 962-7.
  • 14. Gandhi TK, Kachalia A, Thomas EJ, Puopolo AL, Yoon C, Brennan TA, Studdert DM. Missed and delayed diagnoses in the ambulatory setting: a study of closed malpractice claims. Ann Intern Med 2006;145:488-96.
  • 15. Fordyce J, Blank FS, Pekow P, Smithline HA, Ritter G, Gehlbach S, Benjamin E, Henneman PL. Errors in a busy emergency department. Ann Emerg Med 2003;42:324-33.
  • 16. Kuhn G. Circadian rhythm, shift work, and emergency medicine.Ann Emerg Med 2001;37:88-98.
  • 17. Burç H, Baykal B, Atay T, Ünlü EN. Evaluation of common missed fractures and dislocations in orthopedics and traumatology. TOTBİD 2013;12(1):28-34.
  • 18. Lesar TS, Briceland LL, Delcoure K, Parmalee JC, Masta-Gornic V, Pohl H. Medication prescribing errors in a teaching hospital. Jama 1990; 263(17), 2329-2334.
  • 19. NG VCH, LAU FLA. retrospective review of patients with radiological missed fractures in an emergency department in Hong Kong. HKJM 2003;10:215-22.
  • 20. Aaland MO, Smith K. Delayed diagnosis in a rural trauma centre. Surgery 1996;120(4):774-9.
  • 21. Brooks A, Holroyd B, Riley B. Missed injury in major trauma patients. Injury 2004;35:407-10.
  • 22. Laasonen EM, Kivioja A. Delayed diagnosis of extremity injuries in patients with multiple injuries. J Trauma 1991;31(2):257-60.
  • 23. Vles WJ, Veen EJ, Roukema JA, et al. Consequences of delayed discharges in trauma patients: a prospective study. J Am Coll Surg 2003;197(4):596-602.
  • 24. Houshian S, Larsen MS, Holm C. Missed injuries in a level I trauma centre. J Trauma 2002;52(4):715-9.
  • 25. Janjua KJ, Sugrue M, Deane SA. Prospective evaluation of early missed injuries and the role of the tertiary trauma survey. J Trauma 1998;44(6):1000-7.
  • 26. Hoyt DB, Hollingsworth-Fridlund P, Winchell RJ, et al. Analysis of recurrent process errors leading to provider-related complications on an organized trauma service: directions for care improvement. J Trauma 1994;36(3):377-84.
  • 27. Pope JH, Aufderheide TP, Ruthazer R, et al. Missed diagnoses of acute cardiac ischemia in the emergency department. N Engl J Med 2000;342:1163-70.
  • 28. Espinosa JA, Nolan TW. Reducing errors made by emergencyphysicians in interpreting radiographs: longitudinal study. BMJ 2000;320:737-40.
  • 29. Pimentel L, McPherson SJ. Community-acquired pneumonia in theemergency department: a practical approach to diagnosis and management. Emerg Med Clin North Am 2003;21:395-420.
  • 30. Croskerry P. The cognitive imperative: thinking about how wethink. Acad Emerg Med 2000;7:1223-31.
  • 31. Wears RL, Perry SJ. Human factors and ergonomics in theemergency department. Ann Emerg Med 2002;40:206-12.
  • 32. White AA, Wright SW, Blanco R, et al. Cause-and-effect analysisof risk management files to assess patient care in the emergency department. Acad Emerg Med 2004;11:1035-41.
  • 33. McLauchlan CA, Jones K, Guly HR. Interpretation of trauma radiographs by junior doctors in accident and emergency departments: a cause for concern? J Accid Emerg Med 1997;14(5):295-8.
  • 34. Fraser J. The pre-registration year and the undergraduate curriculum. Proc R Soc Med 1973;66:29-30.
  • 35. Mizrahi T. Managing medical mistakes: ideology, insularity and accountability among internists-in-training. Soc sci med 1984;19(2)135-46.
  • 36. Olupeliyawa AM, Hughes C, Balasooriya CD. A review of the literature on teamwork competencies in healthcare practice and training: implications for undergraduate medical education. SEAJME 2009;3(2):61-72.
  • 37. Sexton JB, Thomas EJ, Helmreich RL. Error, stress, and teamwork in medicine and aviation: cross sectional surveys. BMJ 2000;320(7237):745-9.
  • 38. McKee M, Black N. Does the current use of junior doctors in the United Kingdom affect the quality of medical care? Soc sci med 1992;34(5):549-58.
  • 39. Enderson BL, Reath DB, Meadors J, Dallas W, DeBoo JM, Maull KI. The tertiary trauma survey: a prospective study of missed injury. J Trauma 1990;30(6):666-9.
  • 40. Toms AP. The war on terror and radiological error? Clinical radiology 2010;65(8):666-8.
  • 41. Waeckerle JF. A prospective study identifying the sensitivity of radiographic findings and the efficacy of clinical findings in carpal navicular fractures. Ann Emerg Med 1987;16:733-7.
  • 42. Cannon J, Silvestri S, Munro M. Imaging choices in occult hip fracture. J Emerg Med 2009;37:144-52.
  • 43. Livingston DH, Lavery RF, Passannante M, et al. Admission orobservation is not necessary after a negative abdominal computed tomographic scan in patients with suspected blunt abdominal trauma: results of a prospective, multi-institutional study. J Trauma. 1998;44:273-82.
  • 44. Brenner D, Elliston C. Estimated radiation risks potentiallyassociated with full-body CT screening. Radiology 2004;232:735-8.
  • 45. Snyder GE. Whole-body imaging in blunt multisystem trauma patients who were never examined. Ann em med 2008;52(2):101-3.
  • 46. Slovis TL. CT and computed radiography: the pictures are great, but is the radiation dose greater than required? Am J Radiol 2002;179:39-41.
  • 47. Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. N Engl J Med 2000;343:94-9.
  • 48. Richards JR, Derlet RW. Computed tomography for blunt abdominal trauma in the ED: a prospective study. Am J Emerg Med 1998;16:338-42.
There are 49 citations in total.

Details

Primary Language Turkish
Subjects Health Care Administration
Journal Section Articles
Authors

İlker Çolak

Publication Date September 16, 2019
Submission Date January 28, 2019
Published in Issue Year 2019 Volume: 9 Issue: 3

Cite

AMA Çolak İ. Acil Serviste Atlanan Kırık ve Çıkıklarda Tanısal Zorluklar ve Hatalar. Sakarya Tıp Dergisi. September 2019;9(3):379-386. doi:10.31832/smj.518911

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