Missed and Erroneous Diagnoses Common in Primary Care Visits

Ted.E.Palen at KP.ORG Ted.E.Palen at KP.ORG
Sun Dec 8 15:45:51 UTC 2013


The death rate for climbers of K2 (the second highest peak in the world) 
is about 25%.  So although I understand your analogy it is not correct. 
People take huge risks everyday. And they even take more risk with their 
health, although the results of their decision may not have consequences 
for many years. They smoke, drink to excess, become addicted to pain meds, 
eat poor, do not exercise.  Even though diagnostic errors and treatment 
errors may and do have terrible consequences, the behaviors people engage 
in have far more devastating consequences in regard to heart disease, 
cancer, obesity, diabetes, etc. 

Ted E. Palen, PhD MD, MSPH | Physician Investigator | Institute for Health 
Research | Kaiser Permanente Colorado
Physician Manager for Clinical Reporting | Medical Cost Management| 
Colorado Permanente Medical Group
( 303-614-1215 | 7 303-614-1305 | * ted.e.palen at kp.org

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From:   Alan Morris <Alan.Morris at IMAIL.ORG>
To:     IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Date:   12/07/2013 06:08 PM
Subject:        Re: [IMPROVEDX] Missed and Erroneous Diagnoses Common in 
Primary Care Visits



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
Fax: 801-507-4699
e-mail: alan.morris at imail.org
e-mail: alanhmorris at gmail.com

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

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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






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-- 
Peggy Zuckerman
www.peggyRCC.wordpress.com



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