New Study of Dx Error in the Emergency Dept

Jain, Bimal P.,M.D. BJAIN at PARTNERS.ORG
Thu Apr 21 12:49:47 UTC 2016


I agree. Our job as physicians is to diagnose a disease correctly in every patient regardless of whether a presentation is typical or atypical. Therefore a failure to diagnose a disease with atypical presentation should not be considered non-remediable. What we need to do is to understand why such diagnostic errors occur and try to correct them. Such errors occur not only in ED but in primary care settings as well (H. Singh et al, JAMA Intern Med 2013; 173: 418-425; J W Ely et al, JABFM 2012; 25: 85-97).
A major reason for these errors, in my view, is the currently prescribed probabilistic approach to diagnosis in which the low prior probabilities of these diseases would be considered prior evidence against them encouraging failure to suspect or evaluate them. It is for this reason that a probabilistic approach is not employed for diagnosis in CPCs in which diseases with atypical presentations are routinely diagnosed correctly (see my forthcoming paper in Diagnosis ). In my view, the great British statistician Sir Ronald A Fisher got it correct when he commented ‘ In fact, as a matter of principle, the infrequency with which, in particular circumstances, decisive evidence is obtained, should not be confused with the force or cogency of such evidence’ (in his book Statistical Methods and Statistical Inference, page 93 ).

Bimal


Bimal P Jain MD
Pulmonary-CriticalCare
Northshore Medical Center
Lynn MA 01904

From: Mark Gusack [mailto:gusackm at COMCAST.NET]
Sent: Tuesday, April 19, 2016 9:49 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] New Study of Dx Error in the Emergency Dept

Good Evening Peggy:

I agree.  In fact, isn’t it our job as physicians to be on the lookout for ‘atypical’ presentations of diseases?  After all, if it weren’t for these ‘atypical’ presentations then diagnostic criteria would be so easy to apply that an eighth grader could do it.  In fact, a computer could do it…

Hoping to see you at the LA DEM conference.  I plan to submit a number of new posters that may be of interest to you.

Mark Gusack

From: Peggy Zuckerman [mailto:peggyzuckerman at GMAIL.COM]
Sent: Tuesday, April 19, 2016 5:57 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] New Study of Dx Error in the Emergency Dept

Surprises me to see that 'atypical' presentations are thought to be non-remedial.  Why not expand the definition of what is typical, though rarer?

The same kind of thinking that does not permit the 'atypical' presentation to be reviewed properly is where the "classic symptoms" are missing.  Example; in renal cell carcinoma, the 'classic' symptoms are present in fewer than 10% of cases.

Peggy Z

Peggy Zuckerman
www.peggyRCC.com<http://www.peggyRCC.com>

On Tue, Apr 19, 2016 at 2:19 PM, Ruth Ryan <ruthryan at cox.net<mailto:ruthryan at cox.net>> wrote:
A new study by our own peeps.

This is an ED study of 214 diagnostic errors involving most often the most common diagnoses (sepsis, MI, fractures, vascular events) related to the usual suspects of cognitive error and systems problems like high workload. Three quarters involved multiple factors.

Nearly a third were due to patient factors, and a similar number to “atypical” presentations (when will we find a better term for something that happens so often?).

Citation is: Okafor N, Payne VL, Singh H et al. Using voluntary reports from physicians to learn from diagnostic errors in emergency medicine.  Emerg Med J. 2016 Apr;33(4):245-52. doi: 10.1136/emermed-2014-204604. Epub 2015 Nov 3.

Link is: http://www.ncbi.nlm.nih.gov/pubmed/?term=Using+voluntary+reports+from+physicians+to+learn+from+diagnostic+errors+in+emergency+medicine


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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