Background:Missed or delayed diagnosis of acute stroke, or false-negative stroke (FNS), at initial emergency department (ED) presentation occurs in ≈9% of confirmed stroke patients. Failure to rapidly diagnose stroke can preclude time-sensitive treatments, resulting in higher risks of severe sequelae and disability. In this study, we developed and tested a modified version of a structured medical record review tool, the Safer Dx Instrument, to identify FNS in a subgroup of hospitalized patients with stroke to gain insight into sources of ED stroke misdiagnosis.Methods:We conducted a retrospective cohort study at 2 unaffiliated comprehensive stroke centers. In the development and confirmatory cohorts, we applied the Safer Stroke-Dx Instrument to report the prevalence and documented sources of ED diagnostic error in FNS cases among confirmed stroke patients upon whom an acute stroke was suspected by the inpatient team, as evidenced by stroke code activation or urgent neurological consultation, but not by the ED team. Inter-rater reliability and agreement were assessed using interclass coefficient and kappa values (κ).Results:Among 183 cases in the development cohort, the prevalence of FNS was 20.2% (95% CI, 15.0–26.7). Too narrow a differential diagnosis and limited neurological examination were common potential sources of error. The interclass coefficient for the Safer Stroke-Dx Instrument items ranged from 0.42 to 0.91, and items were highly correlated with each other. The κ for diagnostic error identification was 0.90 (95% CI, 0.821–0.978) using the Safer Stroke-Dx Instrument. In the confirmatory cohort of 99 cases, the prevalence of FNS was 21.2% (95% CI, 14.2–30.3) with similar sources of diagnostic error identified.Conclusions:Hospitalized patients identified by stroke codes and requests for urgent neurological consultation represent an enriched population for the study of diagnostic error in the ED. The Safer Stroke-Dx Instrument is a reliable tool for identifying FNS and sources of diagnostic error.

中文翻译：

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Safer Stroke-Dx Instrument：识别急诊科中风误诊

背景：约 9% 的确诊卒中患者在急诊科 (ED) 初次就诊时错过或延迟诊断急性卒中或假阴性卒中 (FNS)。未能快速诊断中风可能会排除对时间敏感的治疗，导致严重后遗症和残疾的风险更高。在本研究中，我们开发并测试了结构化病历审查工具 Safer Dx Instrument 的修改版本，以识别住院卒中患者亚组的 FNS，以深入了解 ED 卒中误诊的来源。在 2 个独立的综合卒中中心进行的回顾性队列研究。在开发和确认队列中，我们应用 Safer Stroke-Dx Instrument 报告 FNS 病例中 FNS 病例中 ED 诊断错误的流行率和记录来源，这些患者被住院团队怀疑为急性中风，如中风代码激活或紧急神经学咨询所证明的那样，但是不是 ED 团队。使用类间系数和 kappa 值 (κ) 评估评分者间的可靠性和一致性。结果：在发展队列的 183 例中，FNS 的患病率为 20.2%（95% CI，15.0-26.7）。过于狭隘的鉴别诊断和有限的神经系统检查是常见的潜在错误来源。Safer Stroke-Dx Instrument 项目的类间系数介于 0.42 至 0.91 之间，且项目之间高度相关。诊断错误识别的 κ 为 0.90（95% CI，0.821–0。978) 使用 Safer Stroke-Dx 仪器。在 99 例确诊队列中，FNS 的患病率为 21.2%（95% CI，14.2-30.3），并确定了类似的诊断错误来源。用于研究 ED 中的诊断错误。Safer Stroke-Dx 仪器是用于识别 FNS 和诊断错误来源的可靠工具。