A Part of the Solution: Reducing Medical Errors in Urgent Care

Abstract & Commentary

By Scott C. Elston, MD, Eastern Regional Medical Director, NextCare Urgent Care, Cary, NC, is Associate Editor for Urgent Care Alert.

Dr. Elston reports no financial relationships relevant to this field of study.

Synopsis: Authors reviewed 181 malpractice claims alleging injury from missed or delayed diagnosis. The most common missed diagnosis was cancer (breast and colorectal). The most common causes were failure to order appropriate tests and inadequate follow-up care.

Source: Gandi TK, et al. Missed and delayed diagnoses in the ambulatory setting: A study of closed malpractice claims. Ann Intern Med. 2006;145;488-496.

In a retrospective study of 181 closed malpractice claims, reviewers determined that the most common causes of missed or delayed diagnosis involved multiple factors — including but not limited to — knowledge and process errors. The majority involved both. Reportedly, 59% of the errors resulted in serious harm, and 30% resulted in death. Fifty-nine percent of these claims involved the diagnosis of cancer (mostly breast [24%] and colorectal [7%]). The most common breakdowns in the diagnostic process were failure to order appropriate diagnostic tests (55%), failure to create a proper follow-up plan (45%), failure to obtain adequate medical history or perform adequate physical examination (42%), and incorrect interpretation of diagnostic tests (37%). A median of 3 process breakdowns occurred per error, and 2 or more were involved in 43% of the cases. Missed cancer diagnoses were more likely to involve diagnostic tests being performed and/or interpreted incorrectly; missed noncancer diagnoses were more likely to involve delays by patients in seeking care, inadequate history or physical examination, and failure to refer.

The most common explanation for physicians not to order appropriate test(s) was seemingly lack of knowledge. The main reasons for inadequate follow-up plans were that none was thought necessary by the physician, an inappropriate interval was chosen, or poor documentation of the plan. While cognitive factors were linked to virtually all diagnostic errors, they were usually accompanied by communication factors, patient-related factors, or other system factors (eg, handoffs).

Commentary

Gandi and colleagues suggest the use of systems interventions and, specifically, the use of the electronic medical record (EMR), with built-in triggers to certain diagnostics given particular complaints/findings, as one possible step toward a reduction of errors. This is certainly likely to be helpful when EMRs become more widespread and sophisticated; however, a more immediate intervention is obviously needed. This intervention will likely remain important in reducing this serious problem, particularly in the fast-paced environment of urgent care. Having comprehensive, efficient, and effective standard operating procedures is a must. However, having staff and providers who are familiar — as well as compliant — is obviously vital to successful implementation. Process errors — as well as knowledge errors — can be reduced to a minimum only with stabilization of the work force and medical staff. Frequent turnover and use of part time/temporary or agency personnel reduces the likelihood that any system — no matter how good — can or will be followed. In the past, many urgent care facilities have been staffed in a chaotic, haphazard fashion, thus, introducing multiple personalities and practice styles that frequently cannot be assessed until after the fact. By stabilizing the clinic staff and medical staff, and creating a standard routine schedule for them, one can then begin the education process regarding operating procedures, as well as medical education issues. This strategy also may be helpful when addressing the issue of follow-up/patient-related factors, and a patient-physician relationship can be fostered. Additionally, by utilizing easy-to-follow systems with built-in safety measures at multiple levels, one can help to reduce/eliminate communication and/or follow-up errors, as well as referral oversights. Use of equally clear standing orders and clinical practice guidelines, along with group and individual educational programs, can likewise assist in reducing the knowledge gap.

As urgent care assumes more of an integral (and recognizable) part of the health care delivery system, practitioners must work to improve and preserve the highest possible quality of care for patients and maintain urgent care's integrity and reputation in the industry. To achieve this goal requires ongoing efforts toward streamlined processes and procedures, and an effort toward stabilization, organization, and education of staff members.