Schiff Gordon D, Hasan Omar, Kim Seijeoung, Abrams Richard, Cosby Karen, Lambert Bruce L, Elstein Arthur S, Hasler Scott, Kabongo Martin L, Krosnjar Nela, Odwazny Richard, Wisniewski Mary F, McNutt Robert A
Division of General Medicine and Primary Care, Brigham and Women's Hospital, 1620 Tremont St, Third Floor, Boston, MA 02120, USA.
Arch Intern Med. 2009 Nov 9;169(20):1881-7. doi: 10.1001/archinternmed.2009.333.
Missed 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.
A 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.
A 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%).
Physicians 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.
漏诊或延迟诊断是患者安全研究中一个常见但研究不足的领域。为了更好地了解此类错误的类型、原因及预防方法，我们对临床医生进行了调查，以征集他们认为的漏诊和延迟诊断病例。
在美国各地的20次大查房中进行了一项包含6个条目的书面调查，并通过邮件向2个合作机构发放。要求受访者报告3例诊断错误病例，并描述他们认为的原因、严重程度和发生频率。
来自22个机构的310名临床医生共报告了669例病例。在排除无诊断错误或细节不足的病例后，还剩下583例。其中，162例错误（28%）被评为严重，241例（41%）为中度，180例（31%）为轻微或不显著。最常见的漏诊或延迟诊断包括肺栓塞（26例[占总数的4.5%]）、药物反应或过量（26例[4.5%]）、肺癌（23例[3.9%]）、结直肠癌（1例[3.3%]）、急性冠状动脉综合征（18例[3.1%]）、乳腺癌（18例[3.1%]）和中风（15例[2.6%]）。错误最常发生在检查阶段（未开具、报告和跟进实验室检查结果）（44%），其次是临床医生评估错误（未考虑和过度权衡其他诊断）（32%）、病史采集（10%）、体格检查（10%）以及转诊或会诊错误和延迟（3%）。
医生能够轻易回忆起多例诊断错误病例，并愿意分享他们的经验。使用一种新的分类工具，并按诊断和错误类型汇总病例，揭示了诊断失败的模式，提示了可改进的领域。对此类错误进行系统的征集和分析可以确定潜在的预防策略。
