Blake Charlton

Inadequacies of Physical Examination as a Cause of Medical Errors and Adverse Events: A Collection of Vignettes

BACKGROUND Oversights in the physical examination are a type of medical error not easily studied by chart review. They may be a major contributor to missed or delayed diagnosis, unnecessary exposure to contrast and radiation, incorrect treatment, and other adverse consequences. Our purpose was to collect vignettes of physical examination oversights and to capture the diversity of their characteristics and consequences. METHODS A cross-sectional study using an 11-question qualitative survey for physicians was distributed electronically, with data collected from February to June of 2011. The participants were all physicians responding to e-mail or social media invitations to complete the survey. There were no limitations on geography, specialty, or practice setting. RESULTS Of the 208 reported vignettes that met inclusion criteria, the oversight was caused by a failure to perform the physical examination in 63%; 14% reported that the correct physical examination sign was elicited but misinterpreted, whereas 11% reported that the relevant sign was missed or not sought. Consequence of the physical examination inadequacy included missed or delayed diagnosis in 76% of cases, incorrect diagnosis in 27%, unnecessary treatment in 18%, no or delayed treatment in 42%, unnecessary diagnostic cost in 25%, unnecessary exposure to radiation or contrast in 17%, and complications caused by treatments in 4%. The mode of the number of physicians missing the finding was 2, but many oversights were missed by many physicians. Most oversights took up to 5 days to identify, but 66 took longer. Special attention and skill in examining the skin and its appendages, as well as the abdomen, groin, and genitourinary area could reduce the reported oversights by half. CONCLUSIONS Physical examination inadequacies are a preventable source of medical error, and adverse events are caused mostly by failure to perform the relevant examination.

The trouble with dabigatran.

Doctors and patients must tread carefully through emerging risks

The Horrible Taste of Nectar and Honey—Inappropriate Use of Thickened Liquids in Dementia: A Teachable Moment

Story From the Front Lines A woman in her 90s with advanced dementia was admitted for stage IV pressure ulcers. She lived at home with her son, who was her primary caregiver and surrogate decision maker. After a hip fracture 1 year prior, she became completely dependent on her son. Because of her dementia, she was started on honey-thickened liquids for aspiration prevention. During the first week of hospitalization, she refused nearly all food and thickened liquids, turning her head when nurses attempted one-on-one feeding. By the end of the week, only her son was able to feed her small amounts of familiar foods. In consultation with the palliative care service, the primary team and son transitioned the patient to inpatient hospice. Her diet was liberalized to regular liquids and her favorite foods. Her intake improved. Two months later, she had gained 8 kg without enduring a clinically significant aspiration event.

Caring for Ivan Ilyich

For over a century, Leo Tolstoy’s The Death of Ivan Ilych has been one of the most influential examinations of how we come to terms with our own mortality. Of the many who care for Ivan Ilych, only the uneducated peasant, Gerasim, is able to help him find meaning and resolution before death. An excerpt that describes Gerasim’s key interaction with Ivan Ilych is provided. Analysis of the text reveals how cultural values may hinder a patient’s ability to confront mortality and how unique social barriers inhibit different caretakers’ ability to care for a dying patient.

Low-Density Lipoprotein Cholesterol Levels and Statin Treatment—A Moving Target?

22. Dormuth CR, Filion KB, Paterson JM, et al; Canadian Network for Observational Drug Effect Studies Investigators. Higher potency statins and the risk of new diabetes: multicentre, observational study of administrative databases. BMJ. 2014;348: g3244. 23. Dormuth CR, Hemmelgarn BR, Paterson JM, et al; Canadian Network for Observational Drug Effect Studies. Use of high potency statins and rates of admission for acute kidney injury: multicenter, retrospective observational analysis of administrative databases. BMJ. 2013;346:f880.

Searching for Joy in Residency by Listening to Our Patients

phrases or answers while driving to and from hospital and while walking my dog. Once I began to approach communication as a procedure, learning it became more exciting. I came to understand that patients and families are not angry at me, but they are emotionally overwhelmed. By paying enough attention to their emotional distress and trying to explain the complicated situation as simply as possible, I discovered, to my great surprise, that they were tremendously grateful for my communication despite the fact that I kept delivering the worst news in the world. After a year-long palliative care fellowship, my communication skills improved considerably. Now I can conduct difficult communication independently, but I realize that mastering family meetings will be a career-long process. It will require continuous deliberate practice for that skill to grow. That is exactly how I felt at the end of my surgical residency. Based on these experiences in both surgery and palliative care, I have learned 2 lessons: communication, like surgery, is not something trainees are (or are not) good at doing by nature. Second, communication skills, like surgical skills, are something that can be taught, learned, and practiced in a structured way. In sharing these lessons with residents and fellows, I have found a way to continue on the path that both my surgical and palliative medicine mentors so deftly laid out for me.

Length of hospitalization and mortality for bleeding during treatment with warfarin, dabigatran, or rivaroxaban

Background Different outcomes among patients hospitalized for bleeding after starting anticoagulation could influence choice of anticoagulant. We compared length of hospitalization, proportion of Intensive Care Unit (ICU) admissions, ICU length of stay, and 30- and 90-day mortality for adults with atrial fibrillation hospitalized for bleeding after starting warfarin, dabigatran, or rivaroxaban. Methods An US commercial database of 38 million members from 1 November 2010 to 31 March 2014 was used to examine adults with atrial fibrillation hospitalized for bleeding after starting warfarin (2,446), dabigatran (442), or rivaroxaban (256). Outcomes included difference in mean total length of hospitalization, proportion of ICU admissions, mean length of ICU stay, and all-cause 30- and 90-day mortality. Results Warfarin users were older and had more comorbidities. Multivariable regression modeling with propensity score weighting showed warfarin users were hospitalized 2.0 days longer (95% CI 1.8–2.3; p < 0.001) than dabigatran users and 2.6 days longer (95% CI 2.4–2.9; p < 0.001) than rivaroxaban users. Dabigatran users were hospitalized 0.6 days longer (95% CI 0.2–1.0; p = 0.001) than rivaroxaban users. There were no differences in the proportion of ICU admissions. Among ICU admissions, warfarin users stayed 3.0 days (95% CI 1.9–3.9; p < 0.001) longer than dabigatran users and 2.4 days longer (95% CI 0.9–3.7; p = 0.003) than rivaroxaban users. There was no difference in ICU stay between dabigatran and rivaroxaban users. There were no differences in 30- and 90-day all-cause mortality. Conclusions Rivaroxaban and dabigatran were associated with shorter hospitalizations; however, there were no differences in 30- and 90-day mortality. These findings suggest bleeding associated with the newer agents is not more dangerous than bleeding associated with warfarin.

Finding the Right Price for Improving Care

The US Food and Drug Administration (FDA) recently approved alirocumab and evolocumab, 2 monoclonal antibody PCSK9 inhibitors that reduce low-density lipoprotein cholesterol. In this edition of JAMA Internal Medicine, Tice et al1 of the Institute for Clinical and Economic Review (ICER) provide a systematic review of the efficacy, safety, and costs of these therapies. These drugs seem to be effective and safe; however, most included trials lasted fewer than 6 months, and none used cardiovascular events as a primary outcome. A metaanalysis of these trials estimates a 50% relative risk reduction of cardiovascular mortality; however, because of the metaanalysis’s limitations, the actual effect on mortality will not be characterized until ongoing trials conclude in 2017. What is novel about this review is the inclusion of cost, the third rail of American medicine. Tice et al1 estimate that treatment with these

Shopping for Direct-to-Consumer Screening: Buyers and Clinicians Beware.

14 000-per-year drugs would cost

A history of physical examination texts and the conception of bedside diagnosis.

300 000 per quality-adjusted life-year gained—well above traditional cost-effectiveness limits. Assuming that only 25% of patients with an FDA-approved indication receive these drugs, the cost to the American health care system would be