Journal review

Chellis M, Olson JE, Augustine J, et al. Evaluation of missed diagnoses for patients admitted from the emergency department. Acad Emerg Med 2001; 8:125-130.

Errors made by ED physicians contributing to misdiagnoses are very low, according to this study from Wright State University and Premier Health Care Services, both based in Dayton, OH. Researchers reviewed the medical records of 5,000 admitted patients. If the ED diagnosis differed from the patient’s discharge diagnosis, the ED record was examined to find out the reason for the misdiagnosis. Here are key findings:

• The study found 28 records that contained errors in the diagnostic process resulting in a misdiagnosis, which comprised 0.6% of patients.

• The most common missed diagnosis was gastrointestinal bleeding/duodenal ulcer, followed by digoxin toxicity and pneumonia.

• Incomplete histories and physical examinations led to many of the errors, which led to misdiagnoses.

• Common diagnoses with ambiguous signs and symptoms, such as urosepsis and digoxin toxicity, were overlooked because appropriate tests were not ordered.

• Elderly patients and patients arriving by emergency medical services were at highest risk for diagnostic errors.

• There was a lack of documentation of a complete physical examination in rectal exams of patients with abdominal pain.

Only three patients had delays in treatment because of the errors in the diagnostic process made by the ED physicians, and no patient suffered a long-term complication. However, the researchers note that patient care can be impacted significantly by information missed during the initial ED evaluation.

They recommend that ED managers perform a chart audit based on ED and final diagnosis, as a quality assurance. "Valuable information can be obtained to improve both physician performance and subsequent patient care," they write.