Abstract
BackgroundDiagnostic errors occur frequently, especially in the emergency room. Estimates about the consequences of diagnostic error vary widely and little is known about the factors predicting error. Our objectives thus was to determine the rate of discrepancy between diagnoses at hospital admission and discharge in patients presenting through the emergency room, the discrepancies’ consequences, and factors predicting them.MethodsProspective observational clinical study combined with a survey in a University-affiliated tertiary care hospital. Patients’ hospital discharge diagnosis was compared with the diagnosis at hospital admittance through the emergency room and classified as similar or discrepant according to a predefined scheme by two independent expert raters. Generalized linear mixed-effects models were used to estimate the effect of diagnostic discrepancy on mortality and length of hospital stay and to determine whether characteristics of patients, diagnosing physicians, and context predicted diagnostic discrepancy.Results755 consecutive patients (322 [42.7%] female; mean age 65.14 years) were included.The discharge diagnosis differed substantially from the admittance diagnosis in 12.3% of cases. Diagnostic discrepancy was associated with a longer hospital stay (mean 10.29 vs. 6.90 days; Cohen’s d 0.47; 95% confidence interval 0.26 to 0.70; P = 0.002) and increased patient mortality (8 (8.60%) vs. 25(3.78%); OR 2.40; 95% CI 1.05 to 5.5 P = 0.038). A factor available at admittance that predicted diagnostic discrepancy was the diagnosing physician’s assessment that the patient presented atypically for the diagnosis assigned (OR 3.04; 95% CI 1.33–6.96; P = 0.009).ConclusionsDiagnostic discrepancies are a relevant healthcare problem in patients admitted through the emergency room because they occur in every ninth patient and are associated with increased in-hospital mortality. Discrepancies are not readily predictable by fixed patient or physician characteristics; attention should focus on context.Trial registrationhttps://bmjopen.bmj.com/content/6/5/e011585
Highlights
Diagnostic errors are frequent, [1,2,3] have severe medical [4, 5] and economic [6] consequences, and account for a considerable proportion of legal claims against physicians. [7,8,9] Emergency medicine is prone to diagnostic error because of its high workload and time pressure, factors competing for attention simultaneously, and potentially life-threatening consequences of wrong diagnoses
[18] studies that heavily rely on expert raters to determine whether a diagnostic error occurred, are susceptible to hindsight [19, 20] and outcome bias. [19, 21] One prominent definition of diagnostic error, which we employ in this study, is based on the discrepancy between the diagnosis under investigation and a more definitive, later diagnosis: Graber defines diagnostic error as a “diagnosis that was unintentionally delayed [ ...], wrong [ ...], or missed [ ...], as judged from the eventual appreciation of more definitive information”. [15]
Several cognitive biases are generally assumed to cause diagnostic error. [22,23,24,25,26] Yet most of these findings are based on retrospective analyses of erroneous cases only or vignette studies in which physicians were tricked into falling prey to cognitive bias. [27,28,29,30,31,32] It remains unclear whether the cognitive processes identified are at work in correctly diagnosed cases, [33] and whether and to what extent they apply in the clinical workplace. [19, 33,34,35] Because many diagnoses are first made in the emergency room where diagnostic error is rife, [10] it is of particular importance to understand the clinically relevant factors associated with discrepancies and these discrepancies consequences in emergency care
Summary
Diagnostic errors are frequent, [1,2,3] have severe medical [4, 5] and economic [6] consequences, and account for a considerable proportion of legal claims against physicians. [7,8,9] Emergency medicine is prone to diagnostic error because of its high workload and time pressure, factors competing for attention simultaneously, and potentially life-threatening consequences of wrong diagnoses. [22,23,24,25,26] Yet most of these findings are based on retrospective analyses of erroneous cases only or vignette studies in which physicians were tricked into falling prey to cognitive bias. [19, 33,34,35] Because many diagnoses are first made in the emergency room where diagnostic error is rife, [10] it is of particular importance to understand the clinically relevant factors associated with discrepancies and these discrepancies consequences in emergency care. Estimates about the consequences of diagnostic error vary widely and little is known about the factors predicting error. Our objectives was to determine the rate of discrepancy between diagnoses at hospital admission and discharge in patients presenting through the emergency room, the discrepancies’ consequences, and factors predicting them
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