Houston VA HSR&D Center of Excellence, Michael E DeBakey Veterans Affairs Medical Center, Houston, Texas, USA.
BMJ Qual Saf. 2012 Feb;21(2):93-100. doi: 10.1136/bmjqs-2011-000304. Epub 2011 Oct 13.
Diagnostic errors in primary care are harmful but difficult to detect. The authors tested an electronic health record (EHR)-based method to detect diagnostic errors in routine primary care practice.
The authors conducted a retrospective study of primary care visit records 'triggered' through electronic queries for possible evidence of diagnostic errors: Trigger 1: A primary care index visit followed by unplanned hospitalisation within 14 days and Trigger 2: A primary care index visit followed by ≥1 unscheduled visit(s) within 14 days. Control visits met neither criterion. Electronic trigger queries were applied to EHR repositories at two large healthcare systems between 1 October 2006 and 30 September 2007. Blinded physician-reviewers independently determined presence or absence of diagnostic errors in selected triggered and control visits. An error was defined as a missed opportunity to make or pursue the correct diagnosis when adequate data were available at the index visit. Disagreements were resolved by an independent third reviewer.
Queries were applied to 212 165 visits. On record review, the authors found diagnostic errors in 141 of 674 Trigger 1-positive records (positive predictive value (PPV)=20.9%, 95% CI 17.9% to 24.0%) and 36 of 669 Trigger 2-positive records (PPV=5.4%, 95% CI 3.7% to 7.1%). The control PPV of 2.1% (95% CI 0.1% to 3.3%) was significantly lower than that of both triggers (p≤0.002). Inter-reviewer reliability was modest, though higher than in comparable previous studies (к=0.37 (95% CI 0.31 to 0.44)).
While physician agreement on diagnostic error remains low, an EHR-facilitated surveillance methodology could be useful for gaining insight into the origin of these errors.
初级保健中的诊断错误是有害的，但很难发现。作者测试了一种基于电子健康记录（EHR）的方法，以检测常规初级保健实践中的诊断错误。
作者对电子查询触发的初级保健就诊记录进行了回顾性研究，以寻找可能存在诊断错误的证据：触发 1：初级保健索引就诊后 14 天内计划外住院；触发 2：初级保健索引就诊后 14 天内≥1 次非计划性就诊。对照就诊既不符合标准 1 也不符合标准 2。电子触发查询应用于 2006 年 10 月 1 日至 2007 年 9 月 30 日期间两个大型医疗保健系统的 EHR 存储库。盲法医生审查员独立确定选定的触发和对照就诊中是否存在诊断错误。当索引就诊时存在足够的数据时，漏诊被定义为错失做出或追求正确诊断的机会。分歧由独立的第三方审查员解决。
查询应用于 212165 次就诊。在记录审查中，作者发现 674 份触发 1 阳性记录中有 141 份（阳性预测值（PPV）=20.9%，95%置信区间 17.9%至 24.0%）和 669 份触发 2 阳性记录中有 36 份（PPV=5.4%，95%置信区间 3.7%至 7.1%）存在诊断错误。对照的 PPV 为 2.1%（95%置信区间 0.1%至 3.3%）明显低于两个触发（p≤0.002）。审查员之间的可靠性适中，尽管高于类似的先前研究（к=0.37（95%置信区间 0.31 至 0.44））。
虽然医生对诊断错误的一致性仍然较低，但 EHR 辅助的监测方法可能有助于深入了解这些错误的来源。
