Missed and Erroneous Diagnosis Common in Primary Care Visits

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© AlexRathsA large variety of common diseases are missed in the primary care setting, and according to a new study, almost 80% of these errors stem from breakowns in the patient – physician clinical encounter.  Most errors also have the potential to cause moderate to severe harm.  Hardeep Singh, MD, MPH, from Baylor College of Medicine in Houston, Texas, and colleagues published their medical record review online on  February 25 in JAMA Internal Medicine.

The authors analyzed 190 primary care diagnostic errors that occurred from October 1, 2006, to September 30, 2007 in a large urban Veterans Affairs facility.    The most commonly missed diagnoses were pneumonia (6.7%), decompensated congestive heart failure (5.7%), acute renal failure (5.3%), and primary cancer (5.3%). Cough was the most common chief presenting symptom associated with a missed diagnosis.  The authors identified several process breakdowns that contributed to missed diagnoses. Process breakdowns involved the patient-physician clinical encounter (78.9%) or stemmed from referrals (19.5%), patient-related factors (16.3%), follow-up and tracking diagnostic information (14.7%), and performance and interpretation of diagnostic tests (13.7%). About half the time (43.7%), more than a single process breakdown contributed to the missed diagnosis.  In interpreting their data, the authors propose that as physicians increasingly rely on technology and team-based care there may be a drop in basic clinical skills and related cognitive processes. Shortened office visits may also exacerbate this problem.  The authors go on to discuss possible solutions.  They suggest that a focus on taking medical histories, performing physical examinations, and ordering tests may help reduce diagnostic error. In addition, it may be helpful to encourage physicians to document a differential diagnosis at the initial visit.
 

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After penning this article, several physicians replied to the article in a Commentary.  “Malpractice claims may capture nonlethal errors; however, they are most often associated with permanent disability or death. Only about 1% of adverse events due to medical negligence result in a claim.” write David E. Newman-Toker, MD and Martin A. Makary, MD, MPH in an accompanying commentary to this article.  The authors go on to state: “Nevertheless, with more than half a billion primary care visits annually in the United States, if the data from Singh et al are generalizable, at least 50 000 missed diagnostic opportunities occur each year at US primary care visits, most resulting in considerable harm. Combining this figure with autopsy-based estimates of US hospital deaths from diagnostic errors (40 000/y to 80 000/y1) and unaccounted nonlethal morbidity from hospital misdiagnoses and acknowledging another half billion visits annually to non“primary care physicians, more than 150 000 patients per year in the United States might have undergone misdiagnosis-related harm.”  In conclusion they state, “Diagnostic errors are associated with substantial harm at individual patient and public health levels, and their burden may be much greater than previously appreciated.” 
 
 Choosing a good primary care physician is very important. Make sure you do your research before going to a new doctor. We’ve outline a check list in a previous blog post. It is also important to make sure you are able to have an open, honest relationship with your doctor to ensure you receive the best care possible.

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