Types and origins of diagnostic errors in primary care settings.
Types and origins of diagnostic errors in primary care settings.
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DOI：
10.1001/jamainternmed.2013.2777
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发表时间：
2013-03-25
影响因子：
39
通讯作者：
Thomas, Eric J.
中科院分区：
文献类型：
--
作者：
Singh, Hardeep;Giardina, Traber Davis;Meyer, Ashley N. D.;Forjuoh, Samuel N.;Reis, Michael D.;Thomas, Eric J.
诊断错误是门诊病人安全的一个未充分研究的方面。确定在初级保健环境中确认的诊断错误病例中遗漏的疾病类型和诊断过程，并确定记录审查是否可以揭示潜在的促成因素，为未来的干预措施提供信息。我们回顾了通过基于电子健康记录的触发器在两个站点检测到的诊断错误的医疗记录。触发因素基于患者在初次初级保健“索引”访视后意外回访的模式。一个更大的城市退伍军人事务设施和一个大型综合私人医疗保健系统。我们的研究集中在2006年10月1日至2007年9月30日期间在初级保健就诊中发现的190例诊断错误。通过病历审查，我们收集了有关索引访问时的症状，漏诊类型，过程故障，潜在的促成因素和错误造成伤害的可能性的数据。在190例病例中，共有68个独特的诊断被遗漏。大多数漏诊是初级保健中的常见疾病，其中肺炎（6.7%）、失代偿性充血性心力衰竭（5.7%）、急性肾衰竭（5.3%）、癌症（原发性）（5.3%）和尿路感染或肾盂肾炎（4.8%）最常见。过程故障最常见的涉及患者-医生临床接触（78.9%），但也与转诊（19.5%），患者相关因素（16.3%），随访和诊断信息跟踪（14.7%），诊断测试的性能和解释（13.6%）。共有43.7%的案件涉及一个以上的这些过程。患者-医生遭遇故障主要与病史采集（56.3%）、检查（47.4%）和/或订购诊断测试以进行进一步检查（57.4%）的问题有关。大多数错误与中度至重度伤害的可能性相关。在我们的研究中发现的诊断错误涉及各种常见疾病，并具有重大的潜在危害。大多数错误与患者-医生临床遭遇中的过程故障有关。预防性干预措施应针对诊断中的共同促成因素，特别是那些涉及患者-医生接触中的数据收集和综合的因素。
Diagnostic errors are an understudied aspect of ambulatory patient safety. To determine the types of diseases missed and the diagnostic process involved in the cases of confirmed diagnosis errors in primary care settings and to determine whether record reviews could shed light on potential contributory factors to inform future interventions. We reviewed medical records of diagnostic errors detected at two sites through electronic health records-based triggers. Triggers were based on patterns of patients’ unexpected return visits after an initial primary care “index” visit. A larger urban Veterans Affairs facility and a large integrated private health care system. Our study focused on 190 unique instances of diagnostic errors detected in primary care visits between October 1, 2006, and September 30, 2007. Through medical record reviews, we collected data on presenting symptoms at the index visit, types of diagnoses missed, process breakdowns, potential contributory factors, and potential for harm from errors. In 190 cases, a total of 68 unique diagnoses were missed. Most missed diagnoses were common conditions in primary care, with pneumonia (6.7%), decompensated congestive heart failure (5.7%), acute renal failure (5.3%), cancer (primary) (5.3%), and urinary tract infection or pyelonephritis (4.8%) being most common. Process breakdowns most frequently involved the patient-practitioner clinical encounter (78.9%) but were also related to referrals (19.5%), patient-related factors (16.3%), follow-up and tracking of diagnostic information (14.7%), and performance and interpretation of diagnostic tests (13.6%). A total of 43.7% of cases involved more than one of these processes. Patient- practitioner encounter breakdowns were primarily related to problems with history-taking (56.3%), examination (47.4%), and/or ordering diagnostic tests for further work-up (57.4%). Most errors were associated with potential for moderate-to-severe harm. Diagnostic errors identified in our study involved a large variety of common diseases and had significant potential for harm. Most errors were related to process breakdowns in the patient-practitioner clinical encounter. Preventive interventions should target common contributory factors across diagnoses, especially those that involve data gathering and synthesis in the patient- practitioner encounter.
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影响因子：
11.4
作者：
Bhasale, AL;Miller, GC;Britt, HC
通讯作者：
Britt, HC
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通讯作者：
Casalino, Lawrence P.
影响因子：
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作者：
Dovey, SM;Meyers, DS;Grob, P
通讯作者：
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