Commonest error in medicine?

Ely, John john-ely at UIOWA.EDU
Tue Nov 25 13:23:23 UTC 2014

I think this has potential.  If we wait for hard data, we'll wait a long time.  We would want to do it systematically with something like a Delphi method.  The most memorable errors might not be the most common or even the most important to try to reduce.  We should consider who to include (primary care, pediatrics, OB-GYN, surgeons, radiologists, pathologists).  I'm guessing misdiagnosis of the common cold is far more common than PE (i.e., calling the common cold bacterial sinusitis).  Maybe we should also collect diagnoses that are never misdiagnosed (sometimes you can learn from the opposite situation).  We should anticipate criticisms - why we should not do this (e.g., it would be based on opinion, not evidence; lots of potential for selection bias; what would an angry grant reviewer say).  We would want to have inclusion and exclusion criteria.  In our checklist study we found lots of potential for misclassification of diagnostic errors, which we defined as an important difference between the initial diagnosis and the one-month follow-up diagnosis.  (Important defined as patient management would have been different).  For example,

1. Evolution of disease:   The diagnosis of viral upper respiratory infection (common cold) may have been correct at the time of the initial visit, but the patient developed bacterial sinusitis after this visit.

2. Nomenclature discrepancy:  The initial diagnosis was "viral illness."  The final diagnosis was "bronchitis" without designating the etiology (which was likely viral).

3. Diagnostic evaluation in process:  The initial diagnosis was nausea of unknown etiology.  Subsequent testing, which was ordered at the initial visit, revealed diabetic gastroparesis.

4. Vague initial impression but specific initial plan:  An initial impression of "abdominal pain" accompanied by a prescription for a proton-pump inhibitor, followed by a final diagnosis of "peptic gastritis."

5. One patient with two diseases:  The chest pain in the emergency room really was caused by reflux esophagitis even though the patient died of a myocardial infarction at home 6 hours later.

6. Discrepancy in disease severity:  A patient with "dehydration" initially treated and released from ER subsequently required admission for the same diagnosis.

In all these cases, the initial diagnosis differed from the one-month follow-up visit, but they were not really "diagnostic errors" the way we usually think of them.

John Ely

From: robert bell [mailto:rmsbell at ESEDONA.NET]
Sent: Monday, November 24, 2014 6:41 PM
Subject: [IMPROVEDX] Commonest error in medicine?

A thought.

Do we know what is the most common serious error in diagnosis in medicine in the USA?

If not can we guess at what is the commonest error in diagnosis? And then perhaps the top five.

Then could we discuss intensely on line and come to conclusions as to how we could lower that rate?

When we have come up with a list of suggestions for that one error we move on to Number 2  on what we think is the list of commonest serious errors in Medicine and how to reduce their incidence.

This way we would be doing something positive rather than just talking. Not that talking is important.

My contribution for serious No. 1 is Pulmonary embolism.

This way we could just on line make a seripous contribution to medicine particularly if someone would write up our discussions.

A thought

Robert M. Bell, M.D., Ph.C.



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