Top

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine

Published in:

Open Access 01-12-2019 | Original research

Diagnostic error increases mortality and length of hospital stay in patients presenting through the emergency room

Authors: Wolf E. Hautz, Juliane E. Kämmer, Stefanie C. Hautz, Thomas C. Sauter, Laura Zwaan, Aristomenis K. Exadaktylos, Tanja Birrenbach, Volker Maier, Martin Müller, Stefan K. Schauber

Published in: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine | Issue 1/2019

Abstract

Background

Diagnostic 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.

Methods

Prospective 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.

Results

755 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).

Conclusions

Diagnostic 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 registration

https://bmjopen.bmj.com/content/6/5/e011585

Available only for authorised users

Balogh EP, Miller BT, Ball JR, editors. Improving diagnosis in health care [internet]. Washington, D.C.: National Academies Press; 2015. https://doi.org/10.17226/21794.CrossRef

Leape LL, Brennan TA, Laird N, Lawthers AG, Localio AR, Barnes BA, et al. The nature of adverse events in hospitalized patients. Results of the Harvard medical practice study II. N Engl J Med. 1991;324:377–84. https://doi.org/10.1056/NEJM199102073240605.CrossRefPubMed

Thomas EJ, Studdert DM, Burstin HR, Orav EJ, Zeena T, Williams EJ, et al. Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care. 2000;38:261–71.CrossRef

Graber M. Diagnostic errors in medicine: a case of neglect. Jt Comm J Qual Patient Saf. 2005;31:106–13.CrossRef

Newman-Toker DE. Diagnostic errors—the next frontier for patient safety. JAMA. 2009;301:1060. https://doi.org/10.1001/jama.2009.249.CrossRefPubMed

Weeks WB, Foster T, Wallace AE, Stalhandske E. Tort claims analysis in the veterans health Administration for Quality Improvement. J Law Med Ethics. 2001;29:335–45. https://doi.org/10.1111/j.1748-720X.2001.tb00352.x.CrossRefPubMed

Brown TW, McCarthy ML, Kelen GD, Levy F. An epidemiologic study of closed emergency department malpractice claims in a national database of physician malpractice insurers. Acad Emerg Med Off J Soc Acad Emerg Med. 2010;17:553–60. https://doi.org/10.1111/j.1553-2712.2010.00729.x.CrossRef

Schaffer AC, Jena AB, Seabury SA, Singh H, Chalasani V, Kachalia A. Rates and characteristics of paid malpractice claims among US physicians by specialty, 1992-2014. JAMA Intern Med. 2017;177:710. https://doi.org/10.1001/jamainternmed.2017.0311.CrossRefPubMedPubMedCentral

Kachalia A, Gandhi TK, Puopolo AL, Yoon C, Thomas EJ, Griffey R, et al. Missed and delayed diagnoses in the emergency department: a study of closed malpractice claims from 4 liability insurers. Ann Emerg Med. 2007;49:196–205. https://doi.org/10.1016/j.annemergmed.2006.06.035.CrossRefPubMed

10.

Ilgen JS, Humbert AJ, Kuhn G, Hansen ML, Norman GR, Eva KW, et al. Assessing diagnostic reasoning: a consensus statement summarizing theory, practice, and future needs. Acad Emerg Med Off J Soc Acad Emerg Med. 2012;19:1454–61. https://doi.org/10.1111/acem.12034.CrossRef

11.

Kämmer JE, Hautz WE, Herzog SM, Kunina-Habenicht O, Kurvers RHJM. The Potential of Collective Intelligence in Emergency Medicine: Pooling Medical Students' Independent Decisions Improves Diagnostic Performance. Med Decis Making. 2017 Aug;37(6):715-724. https://doi.org/10.1177/0272989X17696998.CrossRef

12.

Makary MA, Daniel M. Medical error—the third leading cause of death in the US. BMJ. 2016:i2139. https://doi.org/10.1136/bmj.i2139.

13.

Hautz WE. When I say … diagnostic error. Med Educ. 2018;52:896–7. https://doi.org/10.1111/medu.13602.CrossRef

14.

Zwaan L, Singh H. The challenges in defining and measuring diagnostic error. Diagnosis. 2015;2. https://doi.org/10.1515/dx-2014-0069.CrossRef

15.

Graber ML, Franklin N, Gordon R. Diagnostic Error in Internal Medicine. Arch Intern Med. 2005;165:1493. https://doi.org/10.1001/archinte.165.13.1493.CrossRefPubMed

16.

Newman-Toker DE. A unified conceptual model for diagnostic errors: underdiagnosis, overdiagnosis, and misdiagnosis. Diagn Berl Ger. 2014;1:43–8. https://doi.org/10.1515/dx-2013-0027.CrossRef

17.

Singh H, Meyer AND, Thomas EJ. The frequency of diagnostic errors in outpatient care: estimations from three large observational studies involving US adult populations. BMJ Qual Saf. 2014;23:727–31. https://doi.org/10.1136/bmjqs-2013-002627.CrossRefPubMedPubMedCentral

18.

Berner ES, Graber ML. Overconfidence as a cause of diagnostic error in medicine. Am J Med. 2008;121:S2–23. https://doi.org/10.1016/j.amjmed.2008.01.001.CrossRefPubMed

19.

Wears RL, Nemeth CP. Replacing hindsight with insight: toward better understanding of diagnostic failures. Ann Emerg Med. 2007;49:206–9. https://doi.org/10.1016/j.annemergmed.2006.08.027.CrossRefPubMed

20.

Henriksen K, Kaplan H. Hindsight bias, outcome knowledge and adaptive learning. Qual Saf Health Care. 2003;12(Suppl 2):ii46–50.PubMedPubMedCentral

21.

Caplan RA, Posner KL, Cheney FW. Effect of outcome on physician judgments of appropriateness of care. JAMA. 1991;265:1957–60.CrossRef

22.

Norman GR, Eva KW. Diagnostic error and clinical reasoning. Med Educ. 2010;44:94–100. https://doi.org/10.1111/j.1365-2923.2009.03507.x.CrossRefPubMed

23.

Klein JG. Five pitfalls in decisions about diagnosis and prescribing. BMJ. 2005;330:781.CrossRef

24.

Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med. 2003;78:775–80.CrossRef

25.

Redelmeier DA. The cognitive psychology of missed diagnoses. Ann Intern Med. 2005;142:115–20.CrossRef

26.

Elstein AS. Heuristics and biases: selected errors in clinical reasoning. Acad Med J Assoc Am Med Coll. 1999;74:791–4.CrossRef

27.

Voytovich AE, Rippey RM, Suffredini A. Premature conclusions in diagnostic reasoning. J Med Educ. 1985;60:302–7.PubMed

28.

Schmidt HG, van Gog T, CE Schuit S, Van den Berge K, LA Van Daele P, Bueving H, et al. Do patients’ disruptive behaviors influence the accuracy of a doctor’s diagnosis? A randomised experiment. BMJ Qual Saf. 2017;26:19–23. https://doi.org/10.1136/bmjqs-2015-004109.CrossRefPubMed

29.

Mamede S, Van Gog T, Schuit SCE, Van den Berge K, Van Daele PLA, Bueving H, et al. Why patients’ disruptive behaviors impair diagnostic reasoning: a randomised experiment. BMJ Qual Saf. 2017;26:13–8. https://doi.org/10.1136/bmjqs-2015-005065.CrossRefPubMed

30.

Mamede S, van Gog T, van den Berge K, Rikers RM, van Saase JL, van Guldener C, et al. Effect of availability bias and reflective reasoning on diagnostic accuracy among internal medicine residents. Jama. 2010;304:1198–203.CrossRef

31.

Schmidt HG, Mamede S, van den Berge K, van Gog T, van Saase JLCM, Rikers RMJP. Exposure to media information about a disease can cause doctors to misdiagnose similar-looking clinical cases. Acad Med J Assoc Am Med Coll. 2014;89:285–91. https://doi.org/10.1097/ACM.0000000000000107.CrossRef

32.

Kunina-Habenicht O, Hautz WE, Knigge M, Spies C, Ahlers O. Assessing clinical reasoning (ASCLIRE): instrument development and validation. Adv Health Sci Educ. 2015. https://doi.org/10.1007/s10459-015-9596-y.CrossRef

33.

McLaughlin K, Eva KW, Norman GR. Reexamining our bias against heuristics. Adv Health Sci Educ. 2014;19:457–64. https://doi.org/10.1007/s10459-014-9518-4.CrossRef

34.

Blumenthal-Barby JS, Krieger H. Cognitive biases and heuristics in medical decision making: a critical review using a systematic search strategy. Med Decis Mak Int J Soc Med Decis Mak. 2015;35:539–57. https://doi.org/10.1177/0272989X14547740.CrossRef

35.

Zwaan L, Monteiro S, Sherbino J, Ilgen J, Howey B, Norman G. Is bias in the eye of the beholder? A vignette study to assess recognition of cognitive biases in clinical case workups. BMJ Qual Saf. 2017;26:104–10.CrossRef

36.

Exadaktylos A, Hautz WE. Emergency medicine in Switzerland. ICU Manag Pract. 2015;15:160–2.

37.

Durning SJ, Artino AR, Boulet JR, Dorrance K, van der Vleuten C, Schuwirth L. The impact of selected contextual factors on experts’ clinical reasoning performance (does context impact clinical reasoning performance in experts?). Adv Health Sci Educ Theory Pract. 2012;17:65–79. https://doi.org/10.1007/s10459-011-9294-3.CrossRefPubMed

38.

Weiss SJ, Derlet R, Arndahl J, Ernst AA, Richards J, Fernández-Frankelton M, et al. Estimating the degree of emergency department overcrowding in academic medical centers: results of the national ED overcrowding study (NEDOCS). Acad Emerg Med. 2004;11:38–50.CrossRef

39.

Weiss SJ, Ernst AA, Nick TG. Comparison of the National Emergency Department Overcrowding Scale and the emergency department work index for quantifying emergency department crowding. Acad Emerg Med. 2006;13:513–8. https://doi.org/10.1197/j.aem.2005.12.009.CrossRefPubMed

40.

Morley C, Unwin M, Peterson GM, Stankovich J, Kinsman L. Emergency department crowding: a systematic review of causes, consequences and solutions. Bellolio F, editor. PLoS One. 2018;13:e0203316. https://doi.org/10.1371/journal.pone.0203316.CrossRefPubMedPubMedCentral

41.

Kurmann A, Peter M, Tschan F, Mühlemann K, Candinas D, Beldi G. Adverse effect of noise in the operating theatre on surgical-site infection. Br J Surg. 2011;98:1021–5. https://doi.org/10.1002/bjs.7496.CrossRefPubMed

42.

Nemec M, Koller MT, Nickel CH, Maile S, Winterhalder C, Karrer C, et al. Patients presenting to the emergency department with non-specific complaints: the Basel non-specific complaints (BANC) study. Acad Emerg Med Off J Soc Acad Emerg Med. 2010;17:284–92. https://doi.org/10.1111/j.1553-2712.2009.00658.x.CrossRef

43.

Ruger JP, Lewis LM, Richter CJ. Identifying high-risk patients for triage and resource allocation in the ED. Am J Emerg Med. 2007;25:794–8. https://doi.org/10.1016/j.ajem.2007.01.014.CrossRefPubMed

44.

Sauter TC, Capaldo G, Hoffmann M, Birrenbach T, Hautz SC, Kämmer JE, et al. Non-specific complaints at emergency department presentation result in unclear diagnoses and lengthened hospitalization: a prospective observational study. Scand J Trauma Resusc Emerg Med. 2018;26. https://doi.org/10.1186/s13049-018-0526-x.

45.

Artino AR, Gehlbach H, Durning SJ. AM last page: avoiding five common pitfalls of survey design. Acad Med J Assoc Am Med Coll. 2011;86:1327. https://doi.org/10.1097/ACM.0b013e31822f77cc.CrossRef

46.

Gehlbach H, Artino AR, Durning S. AM last page: survey development guidance for medical education researchers. Acad Med J Assoc Am Med Coll. 2010;85:925. https://doi.org/10.1097/ACM.0b013e3181dd3e88.CrossRef

47.

Manual on the Implementation of ICAO Language Proficiency Requirements. International Civil Aviation Organization; 2004. Report No.: Doc 9835 AN/453.

48.

Naismith LM, Cheung JJH, Ringsted C, Cavalcanti RB. Limitations of subjective cognitive load measures in simulation-based procedural training. Med Educ. 2015;49:805–14. https://doi.org/10.1111/medu.12732.CrossRefPubMed

49.

Demerouti E, Bakker AB, Nachreiner F, Schaufeli WB. The job demands-resources model of burnout. J Appl Psychol. 2001;86:499.CrossRef

50.

Weber N, Brewer N. Confidence-accuracy calibration in absolute and relative face recognition judgments. J Exp Psychol Appl. 2004;10:156–72. https://doi.org/10.1037/1076-898X.10.3.156.CrossRefPubMed

51.

Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40:373–83.CrossRef

52.

Collaborating Centre for Drug Statistics Methodology. The anatomical therapeutic chemical (ATC) classification system - structure and principles [internet]. [cited 22 Feb 2019]. Available: https://www.whocc.no/atc/structure_and_principles/

53.

Hautz SC, Schuler L, Kämmer JE, Schauber SK, Ricklin ME, Sauter TC, et al. Factors predicting a change in diagnosis in patients hospitalised through the emergency room: a prospective observational study. BMJ Open. 2016;6:e011585.CrossRef

54.

World Health Organization. International statistical classification of diseases and related health problems 10th revision [internet]. [cited 29 Apr 2017]. Available: http://apps.who.int/classifications/icd10/browse/2016/en.

55.

Agency for Healthcare Research and Quality. Clinical Classifications Software (CCS) for ICD-10-CM/PCS [Internet]. [cited 29 Apr 2017]. Available: https://www.hcup-us.ahrq.gov/toolssoftware/ccs10/ccs10.jsp

56.

Rubin DB. Inference and missing data. Biometrika. 1976;63:581. https://doi.org/10.2307/2335739.CrossRef

57.

Schafer JL, Graham JW. Missing data: our view of the state of the art. Psychol Methods. 2002;7:147–77. https://doi.org/10.1037/1082-989X.7.2.147.CrossRefPubMed

58.

van BS, Groothuis-Oudshoorn K. Mice : multivariate imputation by chained equations in R. J Stat Softw. 2011;45. https://doi.org/10.18637/jss.v045.i03.

59.

Stekhoven DJ, Bühlmann P. MissForest--non-parametric missing value imputation for mixed-type data. Bioinforma Oxf Engl. 2012;28:112–8. https://doi.org/10.1093/bioinformatics/btr597.CrossRef

60.

Snijders TAB, Bosker RJ. Multilevel analysis: an introduction to basic and advanced multilevel modeling. 2nd edition. Los Angeles London New Delhi Singapore. Washington DC: Sage; 2012.

61.

Newman-Toker DE, Moy E, Valente E, Coffey R, Hines AL. Missed diagnosis of stroke in the emergency department: a cross-sectional analysis of a large population-based sample. Diagnosis. 2014;1:155–66. https://doi.org/10.1515/dx-2013-0038.CrossRefPubMed

62.

Peng A, Rohacek M, Ackermann S, Ilsemann-Karakoumis J, Ghanim L, Messmer AS, et al. The proportion of correct diagnoses is low in emergency patients with nonspecific complaints presenting to the emergency department. Swiss Med Wkly. 2015;145:w14121. https://doi.org/10.4414/smw.2015.14121.CrossRefPubMed

63.

Singh H, Giardina TD, Meyer AND, Forjuoh SN, Reis MD, Thomas EJ. Types and origins of diagnostic errors in primary care settings. JAMA Intern Med. 2013;173:418–25. https://doi.org/10.1001/jamainternmed.2013.2777.CrossRefPubMedPubMedCentral

64.

Zwaan L, de Bruijne M, Wagner C, Thijs A, Smits M, van der Wal G, et al. Patient record review of the incidence, consequences, and causes of diagnostic adverse events. Arch Intern Med. 2010;170:1015–21. https://doi.org/10.1001/archinternmed.2010.146.CrossRefPubMed

65.

Zwaan L, Thijs A, Wagner C, Timmermans DRM. Does inappropriate selectivity in information use relate to diagnostic errors and patient harm? The diagnosis of patients with dyspnea. Soc Sci Med. 2013;91:32–8. https://doi.org/10.1016/j.socscimed.2013.05.001.CrossRefPubMed

66.

Kostopoulou O, Delaney BC, Munro CW. Diagnostic difficulty and error in primary care--a systematic review. Fam Pract. 2008;25:400–13. https://doi.org/10.1093/fampra/cmn071.CrossRefPubMed

67.

Andrews LB, Stocking C, Krizek T, Gottlieb L, Krizek C, Vargish T, et al. An alternative strategy for studying adverse events in medical care. Lancet Lond Engl. 1997;349:309–13. https://doi.org/10.1016/S0140-6736(96)08268-2.CrossRef

68.

Battle RM, Pathak D, Humble CG, Key CR, Vanatta PR, Hill RB, et al. Factors influencing discrepancies between premortem and postmortem diagnoses. JAMA. 1987;258:339–44.CrossRef

69.

Mattsson B, Ertman D, Exadaktylos AK, Martinolli L, Hautz WE. Now you see me: a pragmatic cohort study comparing first and final radiological diagnoses in the emergency department. BMJ Open. 2018;8:e020230. https://doi.org/10.1136/bmjopen-2017-020230.CrossRefPubMedPubMedCentral

70.

Eva KW. On the generality of specificity. Med Educ. 2003;37:587–8.CrossRef

71.

Eva KW. What every teacher needs to know about clinical reasoning. Med Educ. 2005;39:98–106. https://doi.org/10.1111/j.1365-2929.2004.01972.x.CrossRefPubMed

72.

Chellis M, Olson J, Augustine J, Hamilton G. Evaluation of missed diagnoses for patients admitted from the emergency department. Acad Emerg Med. 2001;8:125–30.CrossRef

73.

Van Such M, Lohr R, Beckman T, Naessens JM. Extent of diagnostic agreement among medical referrals. J Eval Clin Pract. 2017. https://doi.org/10.1111/jep.12747.CrossRef

74.

Hautz WE, Kämmer JE, Exadaktylos A, Hautz SC. How thinking about groups is different from groupthink. Med Educ. 2017;51:229. https://doi.org/10.1111/medu.13137.CrossRefPubMed

Title: Diagnostic error increases mortality and length of hospital stay in patients presenting through the emergency room
Authors: Wolf E. Hautz
Juliane E. Kämmer
Stefanie C. Hautz
Thomas C. Sauter
Laura Zwaan
Aristomenis K. Exadaktylos
Tanja Birrenbach
Volker Maier
Martin Müller
Stefan K. Schauber
Publication date: 01-12-2019
Publisher: BioMed Central
Published in: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine / Issue 1/2019
Electronic ISSN: 1757-7241
DOI: https://doi.org/10.1186/s13049-019-0629-z

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Diagnostic error increases mortality and length of hospital stay in patients presenting through the emergency room

Abstract

Background

Methods

Results

Conclusions

Trial registration

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

Trial registration

Please log in to get access to this content

Other articles of this Issue 1/2019

Impact of rewarming rate on the mortality of patients with accidental hypothermia: analysis of data from the J-Point registry

Intra-patient potassium variability after hypothermic cardiac arrest: a multicentre, prospective study

Key performance indicators for pre hospital emergency Anaesthesia - a suggested approach for implementation

Postponing intubation in spontaneously breathing major trauma patients upon emergency room admission does not impair outcome

Impact of traumatic events incurred by asylum-seekers on mental health and utilization of medical services

Road bike accidents involving cervical fractures presenting as cardiac arrest: a report of two cases