BackgroundDiagnostic error is commonly defined as a missed, delayed or wrong diagnosis and has been described as among the most important patient safety hazards. Diagnostic errors also account for the largest category of medical malpractice high severity claims and total payouts. Despite a large literature on the incidence of inpatient adverse events, no systematic review has attempted to estimate the prevalence and nature of harmful diagnostic errors in hospitalised patients.MethodsA systematic literature search was conducted using Medline, Embase, Web of Science and the Cochrane library from database inception through 9 July 2019. We included all studies of hospitalised adult patients that used physician review of case series of admissions and reported the frequency of diagnostic adverse events. Two reviewers independently screened studies for inclusion, extracted study characteristics and assessed risk of bias. Harmful diagnostic error rates were pooled using random-effects meta-analysis.ResultsTwenty-two studies including 80 026 patients and 760 harmful diagnostic errors from consecutive or randomly selected cohorts were pooled. The pooled rate was 0.7% (95% CI 0.5% to 1.1%). Of the 136 diagnostic errors that were described in detail, a wide range of diseases were missed, the most common being malignancy (n=15, 11%) and pulmonary embolism (n=13, 9.6%). In the USA, these estimates correspond to approximately 249 900 harmful diagnostic errors yearly.ConclusionBased on physician review, at least 0.7% of adult admissions involve a harmful diagnostic error. A wide range of diseases are missed, including many common diseases. Fourteen diagnoses account for more than half of all diagnostic errors. The finding that a wide range of common diagnoses are missed implies that efforts to improve diagnosis must target the basic processes of diagnosis, including both cognitive and system-related factors.PROSPERO registration numberCRD42018115186.
Sodic-calcic alteration has affected numerous districts with Laramide porphyry systems 22 across Arizona and New Mexico. Previously undocumented Na-Ca alteration has been identified 23 at Charleston, Sycamore Canyon, Silver Bell, and the Ninetysix Hills in Arizona and the Central 24 mining district in New Mexico. These new occurrences are compared to sodic-calcic alteration at 25 the Sierrita-Esperanza deposit (Pima district), Ajo mining district, Tea Cup pluton (Kelvin-26 Riverside district), and the Eagle Pass dike swarm in Arizona. 27 Spatial positions, crosscutting relationships, and mineral assemblages and compositions 28 allow for interpretation of the geochemical conditions of formation and implications for 29 associated hydrothermal processes. Diopside-or andradite-grossular solid solution (Ad68-Ad72) -30 stable assemblages representative of calcic alteration typically occur in deep and/or distal 31 positions but are less commonly exposed. The sodic-calcic and sodic alteration types, however, 32 occur more proximal to the porphyry orebody. Sodic-calcic assemblages containing Na-33 plagioclase (An10-An33) -Ca-amphibole ± epidote are focused along granite cupolas near the 34 base of orebodies, and these grade into shallower sodic assemblages containing albite (An00-35 An09)epidotechlorite. Mineral composition and fluid inclusion data suggest that Na-Ca 36 plagioclase-bearing assemblages form at higher temperatures (360-470°C+) than later, lower 37 temperature albiteepidote assemblages (>250°C). Calculated δD isotopic compositions of 38 fluids in equilibrium with Na-Ca alteration minerals span a broad range (-46 to -1‰) and are 39 consistently less negative than magmatic fluids. Where members of the Na-Ca family of 40 alteration assemblages are present in porphyry systems, many lines of evidenceincluding 41 isotopic compositions of minerals and the geologic alteration zoning patternsare consistent 42 with an origin by incursion of saline external fluids. 43 Where Na-Ca alteration is present, it is best developed at relatively deep levels of 44 3 porphyry systems. Several Laramide systems that are well exposed at comparably deep levels 45 lack Na-Ca alteration, probably because sources of saline fluid were absent or hydrologic 46 conditions were unfavorable for the incursion of saline external fluids. Though similar in 47 temperatures, isotopic compositions, mineral assemblages, and zoning patterns, Na-Ca alteration 48 in Laramide systems is volumetrically smaller than in Jurassic systems documented in the 49 western United States, probably because saline external fluids were much less abundant during 50the Laramide after a tectonically-driven excursion in paleoclimate from arid to humid conditions. 51 phases of a batholith, whereas variably developed iron oxide-rich alteration in porphyry districts 69 commonly is distal to and at shallower levels than the porphyry intrusions (Carten, 1986; Dilles 70
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