Michael E. DeBakey Veterans Affairs Medical Center, and Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas 77030, USA.
JAMA Intern Med. 2013 Mar 25;173(6):418-25. doi: 10.1001/jamainternmed.2013.2777.
Diagnostic errors are an understudied aspect of ambulatory patient safety.
To determine the types of diseases missed and the diagnostic processes involved in cases of confirmed diagnostic errors in primary care settings and to determine whether record reviews could shed light on potential contributory factors to inform future interventions.
We reviewed medical records of diagnostic errors detected at 2 sites through electronic health record-based triggers. Triggers were based on patterns of patients' unexpected return visits after an initial primary care index visit.
A large urban Veterans Affairs facility and a large integrated private health care system.
Our study focused on 190 unique instances of diagnostic errors detected in primary care visits between October 1, 2006, and September 30, 2007.
Through medical record reviews, we collected data on presenting symptoms at the index visit, types of diagnoses missed, process breakdowns, potential contributory factors, and potential for harm from errors.
In 190 cases, a total of 68 unique diagnoses were missed. Most missed diagnoses were common conditions in primary care, with pneumonia (6.7%), decompensated congestive heart failure (5.7%), acute renal failure (5.3%), cancer (primary) (5.3%), and urinary tract infection or pyelonephritis (4.8%) being most common. Process breakdowns most frequently involved the patient-practitioner clinical encounter (78.9%) but were also related to referrals (19.5%), patient-related factors (16.3%), follow-up and tracking of diagnostic information (14.7%), and performance and interpretation of diagnostic tests (13.7%). A total of 43.7% of cases involved more than one of these processes. Patient-practitioner encounter breakdowns were primarily related to problems with history-taking (56.3%), examination (47.4%), and/or ordering diagnostic tests for further workup (57.4%). Most errors were associated with potential for moderate to severe harm.
Diagnostic errors identified in our study involved a large variety of common diseases and had significant potential for harm. Most errors were related to process breakdowns in the patient-practitioner clinical encounter. Preventive interventions should target common contributory factors across diagnoses, especially those that involve data gathering and synthesis in the patient-practitioner encounter.
诊断错误是门诊患者安全中一个研究不足的方面。
确定在初级保健环境中确诊的诊断错误病例中遗漏的疾病类型和涉及的诊断过程，并确定记录审查是否可以揭示潜在的促成因素，以告知未来的干预措施。
我们通过基于电子健康记录的触发器审查了在 2 个地点检测到的诊断错误的医疗记录。触发器基于患者在初次初级保健就诊后的意外复诊模式。
一个大型城市退伍军人事务设施和一个大型综合私人医疗保健系统。
我们的研究重点是在 2006 年 10 月 1 日至 2007 年 9 月 30 日期间在初级保健就诊中检测到的 190 个独特的诊断错误实例。
通过病历回顾，我们收集了索引就诊时的主要症状、遗漏的诊断类型、流程中断、潜在促成因素以及错误造成的潜在伤害。
在 190 例病例中，共有 68 种不同的诊断被遗漏。大多数遗漏的诊断是初级保健中的常见疾病，最常见的是肺炎（6.7%）、失代偿性充血性心力衰竭（5.7%）、急性肾衰竭（5.3%）、原发性癌症（5.3%）和尿路感染或肾盂肾炎（4.8%）。流程中断最常涉及患者-医生临床接触（78.9%），但也与转诊（19.5%）、患者相关因素（16.3%）、诊断信息的随访和跟踪（14.7%）以及诊断测试的执行和解释（13.7%）有关。共有 43.7%的病例涉及这些过程中的多个。患者-医生接触中断主要与病史采集（56.3%）、检查（47.4%）和/或为进一步检查开诊断性检查（57.4%）有关。大多数错误与潜在的中度至重度伤害相关。
我们的研究中确定的诊断错误涉及大量常见疾病，并有很大的潜在伤害。大多数错误与患者-医生临床接触中的流程中断有关。预防干预措施应针对跨诊断的常见促成因素，特别是涉及患者-医生接触中数据收集和综合的因素。
