Errors of Omission
Abstract & Commentary
By Allan J. Wilke, MD, Residency Program Director, Associate Professor of Family Medicine, University of Alabama at Birmingham School of Medicine—Huntsville Regional Medical Campus. Dr. Wilke reports no financial relationship to this field of study.
Synopsis: A review of ambulatory medical malpractice cases of missed and delayed diagnoses reveals that they result from a witches' brew of multiple breakdowns, cognitive errors, and dysfunctional systems.
Source: Gandhi TK, et al. Missed and Delayed Diagnoses in the Ambulatory Setting: A Study of Closed Malpractice Claims. Ann Intern Med. 2006;145:488-496.
Misdiagnoses are the most common malpractice claims in the United States.1 Reviewing the closed claims of four malpractice insurance companies from 1984 to 2004, Gandhi and associates found 429 alleging injury from missed or delayed diagnoses. Emergency departments accounted for 122 of them; the other 307, from physicians' offices, ambulatory surgery centers, pathology laboratories, and imaging centers, were the subject of this study. The adverse outcomes were scored on a 9-point severity scale from emotional injury only to death. The reviewers classified contributing factors into three groups: cognitive, system, and patient. These factors were evaluated for error, ie, "the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim."2 The errors were then ranked on a 6-point confidence scale from "little or no evidence" to "virtually certain" that the adverse outcome resulted from one or more errors. Any claim ranked 4 or greater was considered to have an error. After review, 181 of the 307 were determined to have diagnostic errors and resultant adverse outcomes.
Of the 181 claims, 106 (59%) involved "significant or major physical outcomes" and 55 (30%) resulted in death. The other 20 were associated with psychological, emotional, or minor physical harm. The most common missed diagnoses were breast cancer (24%), colon cancer (7%), infection (5%), and skin cancer, hematologic cancer, gynecologic cancer, fracture, and myocardial infarction (all at 4%). Primary care physicians were named in 49% of the claims, followed by radiologists (17%), general surgeons (13%), and pathologists (7%). Physicians-in-training accounted for 11% of claims. Breakdown analysis of the diagnostic process demonstrated that some claims had multiple errors and multiple physicians making those errors. The main errors were "failure to order an appropriate diagnostic test," "failure to create a proper follow up plan," "failure to obtain an adequate history or to perform an adequate physical examination," and "incorrect interpretation of a diagnostic test." The most frequent contributing factors were failures in judgment, vigilance or memory, knowledge, lack of patient adherence, atypical presentation, complicated medical history, and communication factors (including handoffs).
Commentary
Wow, where do we start? There are so much data presented in this study and so many ways of looking at them. An abstract from this same group of its study of errors in the emergency department is available on-line.3 Same song, different verse. An editorialist4 wondered how patient safety in the hospital compared with that in the office. Dr. Wachter has the credentials; he is the editor of the Agency for Healthcare Quality and Research's Web M&M (Morbidity and Mortality Rounds on the Web)5 and Chair of the University of California San Francisco Patient Safety Committee. He argues that there are major differences between safety in the hospital and the office. With so many more patients seen in ambulatory settings, the opportunities for disaster (and improvement) are rife. Dr. Wachter promotes electronic medical records as one solution to the problems of physicians not ordering health maintenance testing, not having evidenced-based recommendations at hand to interpret the tests they do order, and not being alerted when patients fail to follow up. He also discusses the enormous upfront costs of acquiring and maintaining EMRs. In a prior life (circa 1995) I was one of those "early adopters" of an EMR. I was looking for all of the previously mentioned benefits, and I wanted it to do real-time drug-drug interaction scanning. It/we failed.
This summer, the Family Medicine Center associated with the residency I direct, implemented an EMR. We are about four months since "go live" and while we seem to be doing a better job of coding our visits, I haven't been impressed that we're making improvements in our patients' safety. The September 2006 issue of the ACGME (Accreditation Council for Graduate Medical Education) Bulletin was devoted to patient safety. I was struck by an article by Deborah Powell, MD, Dean of the University of Minnesota Medical School, who reported on René Amalberti's, MD address to the ACGME meeting last year. "Dr. Amalberti commented that the health care system in the United States could be as safe as commercial aviation, but to accomplish this, the community would need to give up a considerable degree of physician and patient autonomy. He raised the question whether we would be willing, or able, to do that." I'm not so sure we are, but Dr. Powell argues that we must be. Getting back to the commercial aviation industry, Stripe and colleagues modified the risk-management techniques taught to pilots and applied them to malpractice cases. In this limited study, they demonstrated that the "aeronautical cognitive causative approach … [could] reliably identify cognitive causes of errors in a significant proportion of medical malpractice cases … "6 To err is human, to forgive divine. To ignore the problem is criminal. We can and must do better.
References
1. Holohan TV, et al. Analysis of diagnostic error in paid malpractice claims with substandard care in a large healthcare system. South Med J. 2005;98:1083-1087.
2. Kohn LT, et al. To Err Is Human. Building a Safer Health System. Institute of Medicine, Washington, DC: National Academy Press; 1999.
3. Kachalia A, 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]
4. Wachter RM. Is ambulatory patient safety just like hospital safety, only without the "stat"? Ann Intern Med. 2006;145:547-549.
5. www.webmm.ahrq.gov. Accessed November 5, 2006.
6. Stripe SC, Best LG, Cole-Harding S, et al. Aviation model cognitive risk factors applied to medical malpractice cases. J Am Board Fam Med. 2006;19:627-632.
A review of ambulatory medical malpractice cases of missed and delayed diagnoses reveals that they result from a witches' brew of multiple breakdowns, cognitive errors, and dysfunctional systems.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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