Diagnostic errors related to acute abdominal pain in the emergency department.

Mark H Ebell ebell at UGA.EDU
Fri Nov 20 18:38:05 UTC 2015


So, for an asymptomatic person coming in for a health maintenance exam, the history is very important, while the physical examination is incredibly unhelpful. Take the routine skin exam. Even a large state level quasi-experimental/ecologic study in Germany found 1 fewer melanoma death/100,000 in the group that had annual skin exams encouraged. And that study was riddled with potential biases, so this is probably an overestimate of benefit.

On the other hand, for a symptomatic patient with leg or abdominal or chest pain, intelligent use of the physical exam can help us select tests, etc. But I’m continually amazed at just how inaccurate individual findings are. At best, they are helpful at risk stratification when used together as in the Wells rule for PE.

Mark

—
Mark H. Ebell MD, MS
Professor of Epidemiology University of Georgia
Editor, Essential Evidence Deputy Editor, American Family Physician
ebell at uga.edu


From: "Ely, John" <john-ely at UIOWA.EDU<mailto:john-ely at UIOWA.EDU>>
Reply-To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>, "Ely, John" <john-ely at UIOWA.EDU<mailto:john-ely at UIOWA.EDU>>
Date: Friday, November 20, 2015 at 11:54 AM
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] Diagnostic errors related to acute abdominal pain in the emergency department.

We’re not supposed to do complete physical exams anymore.  (http://www.nytimes.com/2015/01/09/opinion/skip-your-annual-physical.html?_r=2)

Next thing you know, they’ll tell us complete histories are also “worthless” or at least not evidence based.

However, I still think we should do both.

John Ely, MD
University of Iowa



From: Bruno, Michael [mailto:mbruno at HMC.PSU.EDU]
Sent: Friday, November 20, 2015 9:52 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] Diagnostic errors related to acute abdominal pain in the emergency department.

Thanks, Julianne, Thanks Ruth.

I’m convinced that a great many diagnostic errors could be avoided by simply improving the quality & comprehensiveness of the H&P.  At our institution, specialist physicians will typically only elicit a focused history within their proscribed purview, and then go on to physically examine only their own small bit of “territory.”  My own PCP has also never done a complete H&P on me, and I’ve been seeing him for years!  It seems to me that the only people who actually perform a comprehensive “top to bottom” H&P anymore are the medical students (who pay us for the privilege).

All the best,

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Michael A. Bruno, M.D., F.A.C.R.
Professor of Radiology & Medicine
Vice Chair for Quality and Patient Safety
Chief, Division of Emergency Radiology
The Milton S. Hershey Medical Center
Penn State College of Medicine
500 University Drive, Mail Code H-066
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Phone: (717) 531-8703
Fax:      (717) 531-5596

e-mail: mbruno at hmc.psu.edu<mailto:mbruno at hmc.psu.edu>


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Thanks

From: Julianne Nemes Walsh [mailto:nemeswalsh at GMAIL.COM]
Sent: Friday, November 20, 2015 10:28 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] Diagnostic errors related to acute abdominal pain in the emergency department.

Thank you Ruth, the data consistent with malpractice claim data findings and certainly an area of focus for preventative educational strategies.

On Thu, Nov 19, 2015 at 5:34 PM, Ruth Ryan <ruthryan at cox.net<mailto:ruthryan at cox.net>> wrote:
I can’t get to the whole article, but here is a link to the abstract.  http://www.ncbi.nlm.nih.gov/pubmed/26531859
Medford-Davis L, Park E, Shlamovitz G, Suliburk J, Meyer AN, Singh H. Diagnostic errors related to acute abdominal pain in the emergency department.
Emerg Med J. 2015 Nov 3. pii: emermed-2015-204754. doi: 10.1136/emermed-2015-204754. [Epub ahead of print]
Of interest, over 1/3 of high risk abdominal pain pts in the ED in this study had diagnostic errors. The most commonly missed diagnoses were gall bladder disease and UTI, confirming once again that it tends to be the most common diagnoses, not the rarest that are misdiagnosed.
2/3 of the cases had breakdowns in the diagnostic process, most often

·        history-taking

·        ordering insufficient tests

·        problems with follow-up of abnormal test results

Ruth

Ruth Ryan RN, BSN, MSW, CPHRM
Medical writer
Risk management/patient safety
Continuing medical education
Telephone (504) 256-8797<tel:%28504%29%20256-8797>
Email ruthryan at cox.net<mailto:ruthryan at cox.net>
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