Missed and Erroneous Diagnoses Common in Primary Care Visits

Robert Bell rmsbell at ESEDONA.NET
Sun Dec 8 02:28:18 UTC 2013


FOR POSTING TO LIST

I am not sure of that 99% accuracy. The accuracy of the interaction needs to be considered as well.

I doubt that 5% of blood measurements are done according to standard recommendations. Right sized cuff, rest prior to taking, supported arm, clothing removed, and consideration of parallax errors, biases, and repeated measurements for greater accuracy, etc., etc.

Stethoscopes in some hands, as mentioned before, must be incredibly inaccurate.

Should we not get the accuracy of the interactions clarified first?

Rob Bell

Sent from my iPad

On Dec 7, 2013, at 5:55 PM, Alan Morris <Alan.Morris at IMAIL.ORG> wrote:

> I propose that an error is any deviation from the intended, evidence-based, target decision.  Some errors are trivial and of little consequence.  Some carry a major risk to the patient. In an unusually tightly controlled ICU at the Hebrew University Hospital in Jerusalem, Gopher et al. reported about 174 clinician interactions/patient/day.  99% of these clinician interactions were performed correctly by RNs and MDs. (It is the rare, if any, clinical unit that can aspire to a 99% correct performance rate.)  However, the 1% error rate led to a major threat to life or limb per patient every other day, on average!  Most people think that technical rock climbing is a dangerous activity.  However, few climbers would ever tie onto a rope and climb, if they thought they would be subjected to a major threat to life or limb every other day because of error.
> 
> Surprising low clinician error rates associated with almost unachievable correct performance, can lead to unacceptable risks to patients.
> 
> Extrapolating these ICU data to the outpatient setting is difficult.  Nevertheless, I believe we should pay attention to all errors, and categorize them with respect to patient risk.
> 
> Have  a nice day.
> 
> Alan H. Morris, M.D.
> Professor of Medicine
> Adjunct Prof. of Medical Informatics
> University of Utah
> 
> Director of Research
> Director Urban Central Region Blood Gas and Pulmonary Laboratories
> Pulmonary/Critical Care Division
> Sorenson Heart & Lung Center - 6th Floor
> Intermountain Medical Center
> 5121 South Cottonwood Street
> Murray, Utah  84157-7000, USA
> 
> Office Phone: 801-507-4603
> Mobile Phone: 801-718-1283
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> From: "Michael.H.Kanter at KP.ORG" <Michael.H.Kanter at KP.ORG>
> Reply-To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>, "Michael.H.Kanter at KP.ORG" <Michael.H.Kanter at KP.ORG>
> Date: Saturday, December 7, 2013 2:02 PM
> To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG" <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
> Subject: Re: [IMPROVEDX] Missed and Erroneous Diagnoses Common in Primary Care Visits
> 
> i would agree that the prevalence of "errors" is much higher.  It sort of depends though on what one means by an "error".  If one counts every adult person seeing a doctor who has not had their blood pressure checked in a long time that does not get a blood pressure check,  every patient age 50-75 not already screened for colon cancer who leaves an office visit without getting screened then or shortly thereafter, every diabetic out of control who does not get needed labs repeated, the prevalence or "errors" is around 50% in a good system and is even higher if one includes non primary care physicians in this which one should in my view.  Most people do not consider these as errors or diagnostic errors which is part of the problem in my view.  What is probably needed to really measure error rates is to be able to more precisely define what an "error" actually is.    Although it sounds simple, it is not.
> 
> Michael Kanter, M.D.
> Regional Medical Director of Quality & Clinical Analysis
> (626) 405-5722 (tie line 8+335)
> THRIVE By Getting Regular Exercise
> 
> NOTICE TO RECIPIENT:  If you are not the intended recipient of this e-mail, you are prohibited from sharing, copying, or otherwise using or disclosing its contents.  If you have received this e-mail in error, please notify the sender immediately by reply e-mail and permanently delete this e-mail and any attachments without reading, forwarding or saving them.  Thank you.
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> 
> 
> From:        Peggy Zuckerman <peggyzuckerman at GMAIL.COM>
> To:        IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> Date:        12/06/2013 12:09 PM
> Subject:        Re: [IMPROVEDX] Missed and Erroneous Diagnoses Common in Primary Care Visits
> 
> 
> 
> 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> 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>
> Reply-To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>, robert bell <rmsbell at ESEDONA.NET>
> Date: Thu, 5 Dec 2013 16:29:10 -0500
> To: <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
> 
> 
> 
> 
> 
> 
> Moderator: Lorri Zipperer Lorri at ZPM1.com, Communication co-chair, Society for Improving Diagnosis in Medicine
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> Moderator: Lorri Zipperer Lorri at ZPM1.com, Communication co-chair, Society for Improving Diagnosis in Medicine
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> Peggy Zuckerman
> www.peggyRCC.wordpress.com
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> Moderator: Lorri Zipperer Lorri at ZPM1.com, Communication co-chair, Society for Improving Diagnosis in Medicine
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