Using electronic health records, researchers at Baylor College of Medicine studied patients who went to the emergency room with acute abdominal pain to evaluate factors contributing to an incorrect diagnosis and found that major causes of misdiagnosis included incomplete or incorrect history or exam and failure to order needed tests to determine the cause of pain. Their report appears today in the Emergency Medicine Journal.
“In looking at the prior emergency medicine literature, abdominal pain was one of the chief complaints that was most frequently associated with diagnostic errors, but it had the least amount of research done on it,” said Dr. Laura Medford-Davis, assistant professor of emergency medicine at Baylor.
“Not only is it fairly common as a presenting symptom, but it’s also one that could be missed or misdiagnosed,” said Dr. Hardeep Singh, associate professor of medicine at Baylor and chief of health policy, quality and informatics program for the Center for Innovations in Quality, Effectiveness and Safety at the Michael E. DeBakey Veterans Affairs Medical Center.
Researchers used electronic health records to develop an electronic trigger to help identify patients who presented with acute abdominal pain, returned within 10 days after their first ER visit and were admitted to the hospital when they returned.
Within this group of 100 people with a higher probability of having a misdiagnosis than all patients seen, they further reviewed electronic records to find 35 diagnostic errors during the initial visits. More than two-thirds of these errors were related to the patient/provider encounter – often problems with the history-taking or exam – or in ordering additional tests, for example, not all necessary tests were ordered at the time patients presented. Researchers also identified a problem with the follow-up of abnormal test results. Two errors potentially could have caused immediate death, one had the potential for very serious damage and two more had the potential for very serious harm.
“Emergency rooms are busy and often chaotic. Moreover, the diagnosis is often not clear when patients first present nor is diagnosis always black and white,” Singh said. “Our methodology of using rigorous reviews overcomes some of the limitations to measure misdiagnosis. Once these measurements are in place, emergency departments can implement improvement strategies for these types of diagnostic errors.”
Researchers note that there needs to be better follow-up and reporting strategies implemented in the emergency room setting, both focused on the provider and the emergency room team. In addition, it’s essential to educate patients of certain risks and what they should do when their condition changes. They also note the need for more emergency department-based intervention programs to detect and reduce the risks they found in the study.
Singh emphasized the importance of this work, citing a recent Institute of Medicine report that concluded that everyone will likely get misdiagnosed in their lifetime.
“It’s important to have improvement strategies, and you cannot improve what you cannot measure, so this essentially is a study that can help us measure one type of emergency room related misdiagnosis. As researchers, we are trying to develop strategies that use electronic health records data to identify which people should be selected for further review and study. Without using a methodology that leverages electronic health record data, it would be really hard to identify which records to view further.”
Others who took part in the study include Elizabeth Park, James Suliburk and Ashley ND Meyer with Baylor and Gil Shlamovitz with the University of Southern California Keck School of Medicine.
Investigators of this study were supported by Baylor College of Medicine, Center for Innovations in Quality, Effectiveness and Safety and the VA Health Services Research and Development.