Study: Missed diagnoses have multiple causes
Study: Missed diagnoses have multiple causes
Process breakdowns often can be identified
What causes missed diagnoses in the ED? A research team from Brigham and Women's Hospital in Boston decided that one of the best places to seek the answer was in actual malpractice cases, so they reviewed 122 closed malpractice claims from four liability insurers in which patients had alleged a missed or delayed diagnosis in the ED. Their findings? Missed ED diagnoses have complex causes and typically result from multiple breakdowns in the diagnostic process and contributing factors.1
The authors used several examples to illustrate their point. One, for instance, involves a 72-year-old woman with a history of angioplasty. She presents by ambulance for chest pain, nausea and vomiting, diarrhea, shortness of breath, and bilateral arm tingling. An electrocardiogram (ECG) revealed new ST depressions that were not diagnosed. The ED physician did not compare it with an old ECG. Cardiac enzyme tests were not ordered. The patient was discharged with a diagnosis of gastroenteritis.
A cardiologist reviewed the ECG later and noted the abnormalities but did not immediately notify the ED. After the ED was notified, the patient was asked to return, but subsequently died from the myocardial infarction (MI).
Like most examples offered in this paper, this case represents "multiple breakdowns," asserts Allen B. Kachalia, MD, JD, associate physician at Brigham and Women's and the paper's lead author. "You had a cardiologist [reviewing the ECG], so even if you argue the ED missed the diagnosis, there was a backup plan in place. However, even though he read the ECG and picked up the problem, it was not communicated in a timely fashion."
The research divides the factors contributing to diagnostic errors into four major categories:
- cognitive factors: judgment, knowledge, vigilance or memory;
- communication factors: handoffs, clear lines of responsibility, conflict;
- systems: supervision, workload, interruptions, fatigue, technology, ergonomics;
- patient-related factors: nonadherence, atypical presentation, complicated history, poor historian.
As far as process breakdowns, key categories were: failure to order appropriate diagnostic or lab tests, inadequate medical history/physical exam, and incorrect interpretation of diagnostic/lab tests.
It's not surprising, then, that the authors concluded that while many potential areas for action were identified, the problem "likely defies simple solutions."
Solving the problem
Nevertheless, Kalachia does have some thoughts on how missed or erroneous diagnoses in the ED can be minimized.
"Most experts would argue that policy change is not enough," he says. "The system needs to be re-geared so information is transmitted more reliably." For example, in the case cited above, the system could be improved so that when the cardiologist flags the MI, there is an easily activated process in place that lets the clinician in the ED know about it right away.
In another of the case examples, Kalachia points out, a young girl presented to the ED with a sore throat four times. During the first visit, a test for streptococcus was taken and was positive, but this was not specifically reported to anyone. "You have to have a procedure in place so that is reported right away," says Kalachia. Exactly how it is to be done may often be institution-specific, he says. "You could do it by e-mail, or have a computer system where you click a button that let the docs know right away, or a nurse could make a phone call," he says. "That's an issue of resources."
When you look at the literature in general, a large portion of adverse events could be mitigated if communication were better, adds Cherri Hobgood, MD, FACEP, associate dean for curriculum and educational development and an attending physician in the ED at the University of North Carolina, Chapel Hill. "One of the very first things in this context is to have an EMR [electronic medical record] that is readily available," Hobgood says. "This is a tremendous asset in enhancing communication across provider lines."
This problem is closely related to transitions in care — better known as handoffs, she says. "Having structured handoffs systematically performed is another excellent method for increasing communication and decreasing information loss," says Hobgood.
Another critical transition, she adds, is that of sending the ED patient home. "Any mechanism that can be used to improve communication with patients and with caregivers at home is very important," she asserts. "That typically entails having very thorough and complete discharge instructions, and if possible, making sure that someone in addition to the patient is there to receive the information."
A great deal of missed diagnoses, she notes, are due to poor histories — often a result of what the patient tells the physician. "It's critical for the patient to come to the ED as prepared as possible or to bring an advocate with them who can help them give the past medical history, the meds they are on, and so forth," Hobgood says.
Reference
- Kachalia A, Gandhi TK, Puopolo AL, et al. Missed and delayed diagnoses in the emergency department: a study of closed malpractice claims from 4 liability insurers. Ann Emerg Med 2006 Sep 22; [Epub ahead of print]. DOI: 10.1016/j.annemergmed.2006.06.035.
Sources
For more information on avoiding missed diagnoses, contact:
- Cherri Hobgood, MD, FACEP, Associate Dean, Curriculum and Educational Development, University of North Carolina, Chapel Hill, NC. Phone: (919) 843-9373.
- Allen B. Kachalia, MD, JD, Associate Physician, Brigham and Women's Hospital, Boston. Phone: (617) 525-7277. E-mail: [email protected].
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