Diagnostic Error in Medicine Analysis of 583 Physician-Reported Errors
Diagnostic Error in Medicine Analysis of 583 Physician-Reported Errors
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DOI：
10.1001/archinternmed.2009.333
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发表时间：
2009-11-09
影响因子：
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通讯作者：
McNutt, Robert A.
中科院分区：
文献类型：
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作者：
Schiff, Gordon D.;Hasan, Omar;McNutt, Robert A.
背景：漏诊或延误诊断是患者安全性研究中一个常见但研究不足的领域。为了更好地了解这种错误的类型，原因和预防，我们调查了临床医生，征求感知的情况下，错过和延误diagnosis.Methods：6项书面调查，在20个大轮介绍在美国各地，并通过邮件在2个合作机构。受访者被要求报告3例诊断错误，并描述其感知的原因，严重性，和frequency.Results：共669例报告的310名临床医生从22个机构。在排除了没有诊断错误或缺乏足够细节的病例后，剩下583例。其中，162个错误（28%）被评为重大错误，241个（41%）被评为中度错误，180个（31%）被评为轻微或无意义错误。最常见的漏诊或延误诊断是肺栓塞（26例病例[占总数的4.5%]）、药物反应或药物过量（26例[4.5%]），肺癌（23例[3.9%]），结直肠癌（19例[3.3%]）、急性冠脉综合征（18例[3.1%]）、乳腺癌（18例[3.1%]）和卒中（15例[2.6%]）。错误最常发生在测试阶段（未能订购、报告和随访实验室结果）（44%），其次是临床医生评估错误（未考虑和过度重视竞争性诊断）（32%）、病史遗漏（10%）、体格检查（10%）、转诊或咨询错误和延误（3%）。医生们很容易回忆起多个诊断错误的案例，并愿意分享他们的经验。使用一种新的分类工具，并按诊断和错误类型汇总病例，揭示了诊断失败的模式，并提出了需要改进的领域。系统地收集和分析这些错误可以确定潜在的预防战略。
Background: Missed or delayed diagnoses are a common but understudied area in patient safety research. To better understand the types, causes, and prevention of such errors, we surveyed clinicians to solicit perceived cases of missed and delayed diagnoses.Methods: A 6-item written survey was administered at 20 grand rounds presentations across the United States and by mail at 2 collaborating institutions. Respondents were asked to report 3 cases of diagnostic errors and to describe their perceived causes, seriousness, and frequency.Results: A total of 669 cases were reported by 310 clinicians from 22 institutions. After cases without diagnostic errors or lacking sufficient details were excluded, 583 remained. Of these, 162 errors (28%) were rated as major, 241 (41%) as moderate, and 180 (31%) as minor or insignificant. The most common missed or delayed diagnoses were pulmonary embolism (26 cases [4.5% of total]), drug reactions or overdose (26 cases [4.5%]), lung cancer (23 cases [3.9%]), colorectal cancer (19 cases [3.3%]), acute coronary syndrome (18 cases [3.1%]), breast cancer (18 cases [3.1%]), and stroke (15 cases [2.6%]). Errors occurred most frequently in the testing phase (failure to order, report, and follow-up laboratory results) (44%), followed by clinician assessment errors (failure to consider and overweighing competing diagnosis) (32%), history Laking (10%), physical examination (10%), and referral or consultation errors and delays (3%).Conclusions: Physicians readily recalled multiple cases of diagnostic errors and were willing to share their experiences. Using a new taxonomy tool and aggregating cases by diagnosis and error type revealed patterns of diagnostic failures that suggested areas for improvement. Systematic solicitation and analysis of such errors can identify potential preventive strategies.