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Missed diagnoses in ED stem from complex causes
Study: Lawsuits result of multiple breakdowns
by Stacey Kusterbeck, Contributing Editor
Missed diagnoses in the ED are typically the result of multiple breakdowns in the diagnostic process, with several contributing factors, according to a new study. Researchers examined 122 closed malpractice claims from four liability insurers in which patients had alleged a missed or delayed diagnosis in the ED.1 "Our study was specifically designed to determine which breakdowns occur and what contributing factors were present," says Allen Kachalia, MD, JD, the study's lead author and associate physician in the department of medicine at Brigham & Women's Hospital in Boston.
Physician reviewers examined each case to determine whether an adverse outcome because of a missed diagnosis had occurred, what breakdowns were involved in the missed diagnosis, and what factors contributed to it. A total of 79 claims (65%) involved missed ED diagnoses that harmed patients, and 48% of the missed diagnoses were associated with serious harm. Thirty-nine percent resulted in death.
Contributing factors identified included failing to order an appropriate diagnostic test (58% of errors), failing to perform an adequate medical history or physical examination (42% of errors), incorrect interpretation of a diagnostic test (37%), and failure to order an appropriate consultation (33%).
The leading contributing factors to the missed diagnoses were cognitive factors (96%), patient-related factors (34%), lack of appropriate supervision (30%), inadequate handoffs (24%), and excessive workload (23%).
An example of an error made due to handoff issues involved a child who came to an ED four times in one week with fever. A throat culture was taken during the first visit and it came back positive, but this was never communicated to a caregiver. "Handoffs occurred less frequently then the cognitive factors, but the cognitive factors can be much more difficult to fix," says Kachalia. "However, people have less tolerance for handoff errors that occur, because these types of mistakes are perceived as highly preventable."
The missed diagnoses were broader in range than the researchers expected, and the lawsuits didn't involve any one specific diagnosis. "If you look at the diagnoses that were missed, there was a large list of them," says Kachalia. "The leading missed diagnoses were fracture, infection, and myocardial infarctions. But all of those together made up less than half of all diagnoses which were missed."
This finding suggests that instead of targeting liability-reduction efforts by individual diagnosis, better results might be achieved by targeting overall processes. "That's not to say that targeting the big diagnosis is not a good idea, because you can get a large number of cases. But if you are trying to get everything, you probably should examine the common processes," Kachalia says.
The fact that over half of errors resulted in part from failing to order diagnostic tests was somewhat surprising, says Kachalia. "Some generally perceive the ED as a place where over ordering of tests may occur, especially due to fears of malpractice suits leading to defensive medicine," he says.
However, when researchers closely examined why diagnostic tests were not ordered, they realized cognitive factors were also involved — in other words, the providers were going down the wrong path to begin with. "That makes sense, because part of the diagnostic evaluation is ordering the correct tests," says Kachalia. "So it was not as surprising when we went back and looked at it."
When the researchers examined reasons for breakdowns causing providers to fail to order tests, they found it was often because the provider didn't believe the tests were required. "A lot of this was due to cognitive factors, which is at the core of human error," says Kachalia. "People will sometimes make judgment errors, forget information, or not have the necessary knowledge that we think they have. That is a core dilemma, and an easy solution to this problem has not been found."
1. 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 2007; 49:196-205.