Study analyzes diagnostic errors in primary care

Diagnostic errors in primary care are often related to process breakdowns during the clinical encounter, according to a new study.

Researchers reviewed medical records of diagnostic errors at two sites, an urban Veterans Affairs facility and an integrated private health care system. The errors were detected by triggers in the electronic health record due to unexpected return visits after a first primary care visit between Oct. 1, 2006, and Sept. 30, 2007. The study's objective was to examine the diseases, diagnostic processes, and contributing factors involved in the errors. Main outcome measures were presenting symptoms at the initial visit, types of missed diagnoses, process breakdowns, possible contributing factors and potential harm. Results were published online Feb. 25 by JAMA Internal Medicine.

One hundred ninety unique diagnostic errors, defined as missed, delayed, or wrong diagnoses, were detected during the study period. Of these, 68 were unique missed diagnoses, including pneumonia (6.7%), decompensated congestive heart failure (5.7%), acute renal failure (5.3%), primary cancer (5.3), and urinary tract infections or pyelonephritis (4.8%).

Process breakdowns were most common during the clinical encounter between the patient and the clinician providing primary care (78.9%) but were also seen in the referral process to other clinicians (19.5%), follow-up and tracking of diagnostic information (14.7%), and performance and interpretation of diagnostic tests (13.7%); patient-related factors, such as provision of inaccurate medical information or problems with effective communication, were involved in 16.3%. More than one of these types of breakdowns was involved in 43.7% of the errors. Breakdowns during the clinical encounter most commonly occurred during the history taking (56.3%), examination (47.4%), or process of ordering further diagnostic tests (57.4%). In addition, 81.1% of cases had no differential diagnosis noted at the initial visit, and previous progress notes were copied and pasted into the index visit notes in 7.4% of cases. Moderate to severe harm was considered possible as a result of most of the errors.

The authors noted that their study was retrospective and that their results may not apply to primary care practices outside integrated health systems, among other limitations. However, they concluded that diagnostic errors in the primary care setting affected a variety of common diseases and could cause significant harm. They pointed out that most of the breakdowns occurred during the clinical encounter, when clinicians have increasingly become more and more pressed for time.

“Our findings highlight the need to focus on basic clinical skills and related cognitive processes (eg, data gathering within the medical history and physical examination and synthesis of data) in the age of increasing reliance on technology and team-based care to improve the health care system,” they wrote. They called for preventive interventions that target common contributing factors, including data gathering and synthesis during the clinical encounter.

An accompanying editorial noted that while important lessons have been learned about diagnostic errors, it is difficult to determine effective solutions. The editorialists noted that generic strategies to reduce errors have not successfully improved patient outcomes. Hybrid fixes may be the best goal, they said, including modifying electronic health record systems so that they can continuously monitor diagnostic performance and provide timely, specific feedback.

“One critical step toward this last approach would be mandatory, structured recording and coding of presenting symptoms, rather than simply diagnoses, in our electronic health record systems,” the editorialists wrote. “This step alone, if consistently performed, would radically transform our ability to track and reduce diagnostic errors.” The editorialists called for all stakeholders to commit to improving diagnostic safety and quality as a top priority.