Missed and Erroneous Diagnoses Common in Primary Care Visits

Robert M Centor rcentor at UAB.EDU
Sun Dec 8 00:42:33 UTC 2013


You have raised a question that likely is unanswerable.   The problem with diagnostic error research is the challenge of who establishes the correct diagnosis.  I believe most studies require experts to review patient files.  I doubt that we could automate diagnostic error assessment.

I do not think the ACA gets us to a unified HER, and that continues to be a huge expensive problem.

==============

Robert M Centor, MD, FACP

Regional Dean, UAB Huntsville Regional Medical Campus
301 Governors Drive
Huntsville, AL 35801

Office: 256-539-7757
Fax: 256-551-4451

Chair-Elect, ACP Board of Regents

Professor, General Internal Medicine
UAB
FOT 720
1530 3rd Ave S
Birmingham, AL 35294-3407
Office: 205-975-4889

From: robert bell <rmsbell at ESEDONA.NET<mailto:rmsbell at ESEDONA.NET>>
Reply-To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>, robert bell <rmsbell at ESEDONA.NET<mailto:rmsbell at ESEDONA.NET>>
Date: Saturday, December 7, 2013 at 2:34 PM
To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>" <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>
Subject: Re: [IMPROVEDX] Missed and Erroneous Diagnoses Common in Primary Care Visits

Thanks all,

Does the affordable care act have the potential to standardize data collection nation wide, and particularly in the area of diagnoses and errors.?

And how would you go about developing a system to collect diagnostic data that gave us correct, inaccurate, and erroneous, diagnostic information?

Rob Bell




On Dec 6, 2013, at 7:28 PM, Janel Hopper <janelhopper at COMCAST.NET<mailto:janelhopper at COMCAST.NET>> wrote:

In the November 2013 issue of Scientific American, the editors pled the need of a system to report electronic medical record errors. There needs to be a way for patients and families to do this since there is a disincentive for doctors to report their own errors. As someone who saw approximately 70 doctors over 40 years, and who had to eventually guess my own diagnosis (pernicious anemia), I feel strongly that there needs to be a way to correct medical records and report errors without further backlash against a patient that underscores the fact that proper differentials were never done.

Sent from my iPhone

On Dec 6, 2013, at 11:42 AM, Peggy Zuckerman <peggyzuckerman at GMAIL.COM<mailto:peggyzuckerman at GMAIL.COM>> wrote:

As a patient, and aware of how very long a diagnosis can take, I find it nearly impossible to believe that the frequency of error is so low.  If I saw two doctors a total of 12 times over six months, in addition to taking 5-6 invasive testing procedures before an actual cause for the problem was found, how many diagnostic errors would be found?  One patient and therefore one error, or the multiple of the visits by the doctors, which could be calculated to be 12?


Without some guidelines to discuss this outside the medical establishment, this issue will have little public support for its correction.  Rather, the average patient, hearing about still another misdiagnosis or lengthy failure to diagnose, will continue to lose faith in the medical system.  Especially with diffuse symptoms, many will wait until something is obvious--and more dangerous--before being seen.
Peggy Zuckerman


On Thu, Dec 5, 2013 at 6:25 PM, Graber, Mark <Mark.Graber at va.gov<mailto:Mark.Graber at va.gov>> wrote:
Rob - thanks for the opportunity to reflect on Hardeep's studies.  Although the focus of the paper was on how well 'trigger tools' worked in helping detect diagnostic errors, there were 3 findings from this and his related papers that in my view are really important:

"First, no differential diagnosis was documented at the index visit in 81.1% of cases"   That's a remarkable finding.  It speaks to the problem of overconfidence and the too-common tendency we all have to satisfice on the first diagnosis that seems to explain all the facts at hand.  How many errors could be avoided if we just thought a little more broadly?  Completing even a modest differential diagnosis might accomplish that.

"Most of the errors identified in our study involved missed diagnosis of a large variety of
common conditions as opposed to either a few selected conditions or rare or unusual diseases."   This corroborates findings from Olga Kostopoulou and others:  Yes, we are likely to miss some rare diseases, but MOST of the diagnostic errors made involve common conditions.  In Hardeep's study these included pneumonia, heart failure, urinary tract infections, etc.  Common stuff.

3.  From Hardeep's data you can calculate an incidence of diagnostic error in ambulatory care:  "Singh et al found that roughly 0.1% of all primary care visits were associated with missed opportunities
to make an earlier diagnosis and prevent "considerable harm."  This is from David Newman-Toker's editorial where he did the math on this.(Measuring diagnostic errors in primary care.  JAMA Intern Med 2013 173(6): 425-6.)  It sounds like we're doing a good job when you think of harm-related errors as being found only once in every 1000 visits, but when you consider that there a half BILIION such visits each year annually, that's a lot of harm.  So the answer to your question is: YES, PRIMARY CARE IS WHERE MOST OF THE ERRORS ARE MADE.  If my math is correct (assuming roughly 5000 hospitals in the US and 500 clinic visits every day), this is what the national and local stats look like.  Its a shocking set of statistics.

Mark Graber, MD FACP


[cid:3469123507_8095274]



________________________________
From: robert bell <rmsbell at ESEDONA.NET<mailto:rmsbell at ESEDONA.NET>>
Reply-To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>, robert bell <rmsbell at ESEDONA.NET<mailto:rmsbell at ESEDONA.NET>>
Date: Thu, 5 Dec 2013 16:29:10 -0500
To: <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>
Subject: [IMPROVEDX] Missed and Erroneous Diagnoses Common in Primary Care Visits

FOR POSTING TO THE LIST

This was published earlier in the year.

http://archinte.jamanetwork.com/article.aspx?articleid=1656540

Is it Primary Care where most diagnostic errors are made?!

Rob Bell

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