Misdiagnosis Rate

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Re: Misdiagnosis Rate

Post by panda » Mon 27 May 2013 0:50

Release Date: 08/27/2012
Each year as many as 40,500 critically ill U.S. hospital patients die with an unknown medical condition that may have caused or contributed to their death, Johns Hopkins patient safety experts report in a recent study.

In a discussion of their findings, described online in BMJ Quality & Safety, researchers say that although diagnostic errors in the intensive care unit (ICU) may claim as many lives each year as breast cancer, they remain an underappreciated cause of preventable patient harm.

“Our study shows that misdiagnosis is alarmingly common in the acute care setting,” says Bradford Winters, M.D., Ph.D., lead author and associate professor of anesthesiology and critical care medicine and neurology and surgery in the Johns Hopkins University School of Medicine. “To date, there’s been very little research to determine root causes or effective interventions,” Winters says, noting that less lethal patient safety risks have received greater attention.

By reviewing studies that used autopsy to detect diagnostic errors in adult ICU patients, the experts in the Johns Hopkins Armstrong Institute for Patient Safety and Quality discovered that 28 percent of patients — more than one in four — had at least one missed diagnosis at death. In 8 percent of patients, the diagnostic error was serious enough that it may either have caused or directly contributed to the individual’s death and, if known, likely would have changed treatment, researchers say. Infections and vascular maladies, such as heart attack and stroke, accounted for more than three-quarters of those fatal flaws.

Overall, the medical conditions most commonly missed by diagnosticians included heart attack; pulmonary embolism, an artery blockage in the lungs; pneumonia; and aspergillosis, a fungal infection that most commonly affects individuals with a weakened immune system. Cumulatively, these four conditions accounted for about one-third of all illnesses that doctors failed to detect.

Their review of 31 studies included 5,863 autopsies from a wide range of ICU types. The prevalence of autopsy-detected misdiagnoses, which were stratified by severity, ranged from 5.5 to 100 percent by study. Winters and his team categorized misdiagnoses based on four categories: vascular, which included conditions involving vessel blockages and bleeding, such as heart attack and stroke; all bacterial, viral and fungal infections; mechanical pathophysiological, a broad range of organ malfunction such as congestive heart failure and bowel obstruction; and cancer/other.

After collecting and classifying all error data, the researchers calculated how frequently misdiagnoses would be discovered if every patient who died in the ICU underwent an autopsy. Although autopsy is more frequently performed in complex patient cases in which the clinician may have a lower level of diagnostic certainty, the authors took this potential bias into account. Based on those adjustments, they say their calculations are conservative estimates.

Winters and his colleagues also found that, when compared with adult hospital patients overall, individuals in the ICU face up to a twofold risk of suffering a potentially fatal diagnostic mistake.

“It may be counterintuitive to think that the patients who are the most closely monitored and frequently tested are more commonly misdiagnosed, but the ICU is a very complex environment,” Winters says. Clinicians face a deluge of information in a distracting environment in which the sickest patients compete for attention, most without being able to communicate with their medical team. “We need to develop better cognitive tools that can take into account the 7,000 or more pieces of information that critical care physicians are bombarded with each day to ensure we’re not ruling out potential diagnoses,” Winters says.

Although two-thirds of discovered misdiagnoses did not directly contribute to the patient’s death, Winters says they’re an important indicator of accuracy and aren’t without costs. Patients may endure lengthened hospital stays, unnecessary surgical procedures and reduced quality of life because of non-fatal diagnostic mistakes, Winters adds.

The Armstrong Institute patient safety experts say the study points to the need for additional research to pinpoint the causes of misdiagnosis and identify tools to help diagnosticians more accurately assess patients.

This research was supported by a National Institute of Health training grant awarded to the Johns Hopkins University School of Medicine and a grant from the Agency for Healthcare Research and Quality (HS017755-01).

Other Johns Hopkins researchers who contributed to this study include Jason Custer, M.D.; Samuel M. Galvagno Jr., D.O., Ph.D.; Elizabeth Colantuoni, M.S., Ph.D.; Shruti G. Kapoor, M.D.; HeeWon Lee, B.A.; Victoria Goode, M.B.A., M.L.I.S.; Karen Robinson, M. Sc., Ph.D.; Atul Nakhasi, B.A.; Peter Pronovost, M.D., Ph.D.; and David Newman-Toker, M.D., Ph.D.
http://www.hopkinsmedicine.org/news/med ... ast_cancer

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Re: Misdiagnosis Rate

Post by radicale » Mon 27 May 2013 0:56

Maybe it's time to replace MD's self-regulated institutions with independent ones.

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Re: Misdiagnosis Rate

Post by panda » Mon 27 May 2013 1:01

Here is the original publication:

BMJ Qual Saf. 2012 Nov;21(11):894-902. doi: 10.1136/bmjqs-2012-000803. Epub 2012 Jul 21.
Diagnostic errors in the intensive care unit: a systematic review of autopsy studies.
Winters B, Custer J, Galvagno SM Jr, Colantuoni E, Kapoor SG, Lee H, Goode V, Robinson K, Nakhasi A, Pronovost P, Newman-Toker D.
Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Baltimore, MD 21287, USA. winters@jhmi.edu

Misdiagnoses may be an underappreciated cause of preventable morbidity and mortality in the intensive care unit (ICU). Their prevalence, nature, and impact remain largely unknown.

To determine whether potentially fatal ICU misdiagnoses would be more common than in the general inpatient population (~5%), and would involve more infections or vascular events.

Systematic review of studies identified by electronic (MEDLINE, etc.) and manual searches (references in eligible articles) without language restriction (1966 through 2011).

Observational studies examining autopsy-confirmed diagnostic errors in the adult ICU were included. Studies analysing misdiagnosis of one specific disease were excluded. Study results (autopsy rate, misdiagnosis prevalence, Goldman error class, diseases misdiagnosed) were abstracted and descriptive statistics calculated. We modelled the prevalence of Class I (potentially lethal) misdiagnoses as a non-linear function of the autopsy rate.

Of 276 screened abstracts, 31 studies describing 5863 autopsies (median rate 43%) were analysed. The prevalence of misdiagnoses ranged from 5.5%-100% with 28% of autopsies reporting at least one misdiagnosis and 8% identifying a Class I diagnostic error. The projected prevalence of Class I misdiagnoses for a hypothetical autopsy rate of 100% was 6.3% (95% CI 4.0% to 7.5%). Vascular events and infections were the leading lethal misdiagnoses (41% each). The most common individual Class I misdiagnoses were PE, MI, pneumonia, and aspergillosis.

Our data suggest that as many as 40,500 adult patients in an ICU in USA may die with an ICU misdiagnoses annually. Despite this, diagnostic errors receive relatively little attention and research funding. Future studies should seek to prospectively measure the prevalence and impact of diagnostic errors and potential strategies to reduce them.
http://www.ncbi.nlm.nih.gov/pubmed/22822241 [abstract]

http://qualitysafety.bmj.com/content/ea ... 3.abstract

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Re: Misdiagnosis Rate

Post by panda » Mon 27 May 2013 2:08

Presentation slides:

ICU Misdiagnosis
Bradford D. Winters, Ph.D., M.D.
The Johns Hopkins Quality and Safety Research Group
• MisDx incidence is significant
• MisDx related harm likely results from both wrong/delayed Dx and complications from inappropriate testing/treatment.
• Class II/III errors>Class I; sign of systemic problems? (what about Class IV?)
• This data only scratches the surface as it does not account for non-lethal morbidity and suffering.
http://www.smdm.org/diagnostic_errors/d ... tation.pdf

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Re: Misdiagnosis Rate

Post by panda » Mon 27 May 2013 4:55

Am J Med. 2008 May;121(5 Suppl):S2-23. doi: 10.1016/j.amjmed.2008.01.001.
Overconfidence as a cause of diagnostic error in medicine.
Berner ES, Graber ML.
Department of Health Services Administration, School of Health Professions, University of Alabama at Birmingham, Birmingham, Alabama, USA. eberner@uab.edu
The great majority of medical diagnoses are made using automatic, efficient cognitive processes, and these diagnoses are correct most of the time. This analytic review concerns the exceptions: the times when these cognitive processes fail and the final diagnosis is missed or wrong. We argue that physicians in general underappreciate the likelihood that their diagnoses are wrong and that this tendency to overconfidence is related to both intrinsic and systemically reinforced factors. We present a comprehensive review of the available literature and current thinking related to these issues. The review covers the incidence and impact of diagnostic error, data on physician overconfidence as a contributing cause of errors, strategies to improve the accuracy of diagnostic decision making, and recommendations for future research.
Doctors think a lot of patients are cured who have simply quit in disgust.
— attributed to Don Herold[85]
As Kirch and Schafii[78] note, autopsies not only document the presence of diagnostic errors, they also provide an opportunity to learn from one’s errors (errando discimus) if one takes advantage of the information. The rate of autopsy in the United States is not measured any more, but is widely assumed to be significantly <10%. To the extent that this important feedback mechanism is no longer a realistic option, clinicians have an increasingly distorted view of their own error rates.
http://www.ncbi.nlm.nih.gov/pubmed/18440350 [abstract]

http://mail.ny.acog.org/website/EFM/Overconfidence.pdf [free full text, pdf]

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Re: Misdiagnosis Rate

Post by radicale » Mon 27 May 2013 23:07

When doctors make bad calls
http://www.theglobeandmail.com/life/hea ... /?page=all
Joel had seen his family doctor the week before, having woken up one day covered in round, bull's-eye-like splotches and with a shivering case of the flu. He could barely stay awake for three hours at the time. As patients do these days, we went online: He was just home from renovating our cottage in Nova Scotia, so maybe it was a cold-water rash from swimming in the ocean (a preposterous case of what doctors disparagingly call “cyberchondria”).

However, a physician friend, after hearing about an unusual “spider” bite on Joel's stomach, suggested Lyme disease – a potentially serious, relatively rare illness caused by deer-tick bites. He had seen cases before.

But Joel's family doctor had not, and he had not been convinced: He had reluctantly ordered the blood test for Lyme disease, given him some oral antibiotics and sent him home. The morning of the facial droop, his reaction was no more urgent: He said Joel had Bell's palsy, a fairly common and benign condition that usually appears for no reason and goes away on its own. We could go to the emergency room, but his attitude was that we were overreacting.

At emergency, we saw a polite, professional young doctor. We asked him about Lyme disease. No, he said. It was definitely Bell's palsy. Joel should not worry, and return to work – even though he could no longer speak clearly and could barely see.

The doctor never asked what Joel did for a living: He's a church minister.

But why had he tried to climb out of the car? That was just stress. When we pressed, the doctor reluctantly referred us to a specialist, but the appointment would be more than six weeks later.

This is where doubt sets in, as patients often find – the fear that you are making a fuss over nothing. But finally, our doctor friend told a colleague, and the infectious-disease clinic called the next day.


But the young ER doctor who told Joel to go back to work, or the older physician who sent Ms. Thomas home to take Tums may never have discovered their errors. That's the truly tragic medical blunder, as Dr. Goldman and Dr. Croskerry would say – the failure to learn from a mistake, so it doesn't happen again.

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