Diagnostic Errors — symptom to treatment disconnect

DX Doc

Making a diagnosis is difficult.  And, doctors sometimes get it wrong.  “Wrong” is often harmless, usually expensive,  and sometimes deadly.

An article about incorrect diagnosis appeared this month in the British Medical Journal Quality and Safety which has been widely reported, including by the Wall Street Journal.  Dr. Tehrani and his co-authors  correlated health insurance claims (diagnosis) with malpractice suits.  They found “diagnostic errors appear to be the most common, most costly and most dangerous of medical mistakes.”

One might think the errors happen because the underlying problem is very rare.  On the contrary, the bulk of errors happen with common conditions.

Another article this month in JAMA Internal Medicine  by Dr. Singh and co-workers reported on common types of diagnostic errors — many of which were common in primary care:  (italics are blog examples)

  • Pneumonia
    • no chest x-ray for cough and high fever
  • Decompensated congestive heart failure
    • no BNpeptide checked
  • Acute renal failure
    • no check of basic metabolic panel for fatigue
  • Cancer
    • ignoring Mammogram findings or blood in sputum
  • Urinary tract infections
    • not checking urinalysis or treating soon enough

The flaw in the process that contributed to the wrong diagnosis included:

  • Inadequate patient encounter (too short or not focused on problem)
  • Not seeking referral when needed (like not getting a cardiology consult for chest pain)
  • Patient related factors (not returning for follow-up)
  • Not taking risk factors into account (like family history of colon cancer)
  • Losing track of test results (urinalysis report filed but not viewed)
  • Not getting the right test (not getting a chest x-ray for shortness of breath)

Problems at the time of patient encounter are a major contributor:

  • Poor history taking (provider did not listen or ask questions)
  • Inadequate examination (provider did not examine problem area — like a breast nodule)
  • Inadequate testing (not considering a colonoscopy for blood in the stool)

When a person has a health problem the whole idea is to connect the dots …problem…diagnosis…treatment.  If the diagnosis is not correct then good treatment is disconnected.

Providers often do not consider enough possible causes for abnormal findings.  Those possibilities are called the “differential diagnosis”.  There are books and several free sites on the Internet that provide such lists.  One such site is DiagnosisPro.  If you like other sites leave a comment please.  Some electronic record applications include a differential diagnosis automatically — nice feature which should always be installed.

So, what is the solution?  Most experts agree, the quality of the provider-patient interaction must improve.  Providers need to follow known guidelines plus use differential diagnosis aids.  Patients need to look out for themselves by using the Internet or books to  understand symptoms and test results.  The best solution is a stronger partnership between patients and providers.  See earlier posts in this blog about shared decision-making and patient centered care.

Can all errors be prevented?  NO.  To err is human.  The point is to minimize the errors, and there is obviously a lot of room for improvement.

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