Richard I. Abrams

Diagnostic Error in Medicine: Analysis of 583 Physician-Reported Errors

BACKGROUNDnMissed or delayed diagnoses are a common but understudied area in patient safety research. To better understand the types, causes, and prevention of such errors, we surveyed clinicians to solicit perceived cases of missed and delayed diagnoses.nnnMETHODSnA 6-item written survey was administered at 20 grand rounds presentations across the United States and by mail at 2 collaborating institutions. Respondents were asked to report 3 cases of diagnostic errors and to describe their perceived causes, seriousness, and frequency.nnnRESULTSnA total of 669 cases were reported by 310 clinicians from 22 institutions. After cases without diagnostic errors or lacking sufficient details were excluded, 583 remained. Of these, 162 errors (28%) were rated as major, 241 (41%) as moderate, and 180 (31%) as minor or insignificant. The most common missed or delayed diagnoses were pulmonary embolism (26 cases [4.5% of total]), drug reactions or overdose (26 cases [4.5%]), lung cancer (23 cases [3.9%]), colorectal cancer (19 cases [3.3%]), acute coronary syndrome (18 cases [3.1%]), breast cancer (18 cases [3.1%]), and stroke (15 cases [2.6%]). Errors occurred most frequently in the testing phase (failure to order, report, and follow-up laboratory results) (44%), followed by clinician assessment errors (failure to consider and overweighing competing diagnosis) (32%), history taking (10%), physical examination (10%), and referral or consultation errors and delays (3%).nnnCONCLUSIONSnPhysicians readily recalled multiple cases of diagnostic errors and were willing to share their experiences. Using a new taxonomy tool and aggregating cases by diagnosis and error type revealed patterns of diagnostic failures that suggested areas for improvement. Systematic solicitation and analysis of such errors can identify potential preventive strategies.

Contextual Errors and Failures in Individualizing Patient Care: A Multicenter Study

BACKGROUNDnA contextual error occurs when a physician overlooks elements of a patients environment or behavior that are essential to planning appropriate care. In contrast to biomedical errors, which are not patient-specific, contextual errors represent a failure to individualize care.nnnOBJECTIVEnTo explore the frequency and circumstances under which physicians probe contextual and biomedical red flags and avoid treatment error by incorporating what they learn from these probes.nnnDESIGNnAn incomplete randomized block design in which unannounced, standardized patients visited 111 internal medicine attending physicians between April 2007 and April 2009 and presented variants of 4 scenarios. In all scenarios, patients presented both a contextual and a biomedical red flag. Responses to probing about flags varied in whether they revealed an underlying complicating biomedical or contextual factor (or both) that would lead to errors in management if overlooked.nnnSETTINGn14 practices, including 2 academic clinics, 2 community-based primary care networks with multiple sites, a core safety net provider, and 3 U.S. Department of Veterans Affairs facilities.nnnMEASUREMENTSnPrimary outcomes were the proportion of visits in which physicians probed for contextual and biomedical factors in response to hints or red flags and the proportion of visits that resulted in error-free treatment plans.nnnRESULTSnPhysicians probed fewer contextual red flags (51%) than biomedical red flags (63%). Probing for contextual or biomedical information in response to red flags was usually necessary but not sufficient for an error-free plan of care. Physicians provided error-free care in 73% of the uncomplicated encounters, 38% of the biomedically complicated encounters, 22% of the contextually complicated encounters, and 9% of the combined biomedically and contextually complicated encounters.nnnLIMITATIONSnOnly 4 case scenarios were used. The study assessed physicians propensity to make errors when every encounter provided an opportunity to do so and did not measure actual error rates that occur in primary care settings because of inattention to context.nnnCONCLUSIONnInattention to contextual information, such as a patients transportation needs, economic situation, or caretaker responsibilities, can lead to contextual error, which is not currently measured in assessments of physician performance.nnnPRIMARY FUNDING SOURCEnU.S. Department of Veterans Affairs Health Services Research and Development Service

A model of medical error based on a model of disease: interactions between adverse events, failures, and their errors.

This article discusses Rush-Presbyterian-St. Lukes Medical Centers approach to assessing and preventing errors in care and promoting patient safety. The word error is applied to all kinds of events, including adverse occurrences, negligence, and malpractice. Thus confusion exists among those analyzing the causes of adverse events. A patient safety committee standardized the definition of medical error and developed a taxonomy for error as a prelude to efforts at error reduction. It identified three levels or layers that can represent a train of events culminating in an undesired outcome: error, treatment failure, and adverse event. This discussion is offered in the interest of clarifying some of the issues.

Avoiding Free Care at All Costs: A Survey of Uninsured Patients Choosing Not to Seek Emergency Services at an Urban County Hospital

The purpose of this case study was to understand why many uninsured patients opt not to make use of a free public hospital when it is available, instead seeking emergency department care at sites where they will be billed for the services they receive. One hundred fifty seven uninsured patients were interviewed over an 8-week period at three emergency departments that bill for services near a county hospital that provides free care. Data was gathered on income, health status, and credit history. Subjects were also asked if they had previously sought care at the county hospital and, if they had, how satisfied they were with the quality of care and with the wait time. Seventy two percent of the subjects reported household incomes of <

Managing the Unmanaged : A Case Study of Intra-institutional Determinants of Uncompensated Care at Healthcare Institutions With Differing Ownership Models

20,000, 48% reported they were in fair or poor health, and 33% said they were unable to pay at least one medical bill at the site where they were seeking care. 65% reported they had previously received care at the county hospital, and of these 61% said they were not-too-likely or not-at-all likely to return. In a regression analysis, experience with wait time correlated with subjects willingness to return, whereas their satisfaction with quality, their income, problems with debt, and reported health status did not. Access involves more than geographic proximity and affordability. Excessive wait times can deter even patients who are poor, in ill health and in debt from making use of services that are intended for their benefit.

How do clinical competency committees use different sources of data to assess residents’ performance on the internal medicine milestones?A mixed methods pilot study

Study Objective:This study presents a case analysis of how 3 urban medical centers with differing ownership models, within 1 metropolitan area, ration access to uncompensated care to uninsured patients. Methods:Data was triangulated from 3 sources: hospital financial reports by service line for a fiscal year, a survey of 292 self-pay patients, and the self-pay policies and practices of clerical personnel described in a previous publication. Results:Although the public, for-profit and not-for-profit institutions used different strategies for managing self-pays, there were also commonalities in the experiences indigent patients reported. The public institution provided the broadest access to the largest percentage of self-pay patients but offset the burden with the most successful prepayment and collection practices. The for-profit site obeyed federal regulations mandating emergency care but severely curtailed other services, and the not-for-profit limited assess (but not to the extent of the for-profit) and pursued collection (but not to the extent of the public). At all sites, actual practices by clerical staff often diverged from institutions’ written self-pay policies. The probability of being turned away because of inability to pay ranged from 0% to 40% with front line personnel exercising considerable discretion on a case-by-case basis. Conclusions:Large institutional providers balance their particular social and legal obligations with strategies to limit access and optimize prepayment and collection. Stated policies generally do not reflect the practices of personnel. Uninsured patients are forced to navigate a capricious system that manages them as a liability rather than as a legitimate client.

An exploratory analysis of the correlation of pain scores, patient satisfaction with relief from pain, and a new measure of pain control on the total dose of opioids in pain care.

Abstract Purpose: This study examines how Clinical Competency Committees (CCCs) synthesize assessment data to make judgments about residents’ clinical performances. Methods: Between 2014 and 2015, after four six-month reporting periods to the Accreditation Council for Graduate Medical Education (ACGME), 7 of 16 CCC faculty at Rush University Medical Center completed questionnaires focused on their perspectives about rating residents on their achievement of the milestones and participated in a focus group. Qualitative data were analyzed using grounded theory. Milestones ratings for two six-month ACGME reporting cycles (nu2009=u2009100 categorical residents) were also analyzed. Results: CCC members weighted resident rotation ratings highest (weightu2009=u200937%), followed by faculty rotation comments (weightu2009=u200927%) and personal experience with residents (weightu2009=u200914%) for making judgments about learner’s milestone levels. Three assessment issues were identified from qualitative analyses: (1) “design issues” (e.g. problems with available data or lack thereof); (2) “synthesis issues” (e.g. factors influencing ratings and decision-making processes) and (3) “impact issues” (e.g. how CCC generated milestones ratings are used). Conclusions: Identifying factors that affect assessment at all stages of the CCC process can contribute to improving assessment systems, including support for faculty development for CCCs. Recognizing challenges in synthesizing first and second-hand assessment data is an important step in understanding the CCC decision-making process.

A rare highly aggressive tumour: lymphoepithelioma-like thymic carcinoma

Objective: We explored the associations between opioid dose and multiple measures of pain. Study Design and Measures: Thirty-two consecutive patients admitted solely for an acute exacerbation of cancer-related pain or for surgery were followed for their entire hospital stay (115 days of pain). For each hospital day, we collected pain scores, the number of pain scores, trends in pain scores, the percentage of time patients had 100% acceptable relief from pain, and the number of times patients were asked about acceptable pain relief. Finally, we asked those who had 100% relief of pain whether they could have used more pain medicine. Linear regression models were fit to estimate the amount of variation explained (R2) in dose of medication, by each pain measurement variable. Results: Nineteen patients with cancer (74 days of pain) and 13 patients undergoing surgery (41 days of pain) were evaluated. Pain scores, the number of pain scores, trends in pain scores, and 100% acceptable relief scores poorly correlated with the use of medication in the linear regression models (R2 for all models ⩽0.2). A question about needing more pain medicine explained the greatest amount of variation in opioid dose. Conclusions: Pain and acceptable relief scores do not adequately reflect the use of medication. A prospective study is needed to further assess the value of additional measures of the adequacy of pain care.

Rationing access to care to the medically uninsured: the role of bureaucratic front-line discretion at large healthcare institutions.

Lymphoepithelioma-likethymic carcinoma is a rare neoplasm that presents with compressive symptoms or as an incidental radiological finding of an anterior mediastinal mass. It is an aggressive carcinoma with a high rate of invasion, metastasis and recurrence. Its diagnosis usually carries a poor prognosis largely due to propensity for late diagnosis. To date, guidance for treatment remains limited. This is a case of lymphoepithelioma-like thymic carcinoma in a young male adult who presented initially with back pain. Despite prompt initiation of chemotherapy with cisplatin, doxorubicin and cyclophosphamide, he had a complicated hospital course leading to demise within 2u2009months of diagnosis.