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  • 1.  Diagnostic Error in Emergency Medicine - AHRQ Evidence Review

    Posted 03-13-2022 16:57
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    A major review of diagnostic error in the ED is now published in draft form on the AHRQ website.  This is a very important and well-done report, with a ton of data and analysis, that will serve as a landmark in this area.  A copy is attached.


    The draft is open for comments until the end of the month, and I would encourage everyone to take this opportunity to provide feedback on the report.  In particular, I call your attention to one area that bothered me, concerning the recommendations section starting on Page 81.  The authors recommend that future interventions focus solely on disease-specific approaches.  Interventions relating to education, improving cognition and clinical reasoning, and patient-focused solutions aren't mentioned at all.  I would like to see a major report like this present a more balanced overview of the many possible interventions that could have impact in the ED, in addition to the disease-specific approaches.


    You can provide feedback on the draft report here:  https://effectivehealthcare.ahrq.gov/products/form/diagnostic-errors-emergency



    Mark L Graber MD FACP

    Founder and President Emeritus, Society to Improve Diagnosis in Medicine

    Professor Emeritus, Stony Brook University, NY

    Cell:  919 667-8585


    Text  Description automatically generated with medium confidence





  • 2.  RE: Diagnostic Error in Emergency Medicine - AHRQ Evidence Review

    Posted 03-13-2022 17:17
    Dear Mark,
    In this draft, I do not immediately see a characterization of the diagnostic error that occurs when a patient's underlying serious disease is not diagnosed, "in favor" of another, less serious disease.  Thinking here of the 'stomach ache' or 'pulled muscle causing back pain' that has been ongoing and finally brought the patient to the ER, and which is a signal of underlying tumor growth.  In the kidney cancer world, this scenario which may even include imaging for a cracked rib, is reported in at least 30-40% of cases ultimately diagnosed.  I see no way that this type of misdiagnosis is likely to be attributed to the lack of diagnosis at the ER.  How can this measured?

    With that, I assume that this is common in other diseases which are not diagnosed, with the patient being sent back to a local GP, who likely lacks imaging devices that are readily available in the ER setting.  Does that GP also rely on the expertise of the ER doctor, to the detriment of the patient in need of an accurate diagnosis?  

    This type of missed diagnosed is especially common where the patient population does not have a regular GP or has sporadic care through Urgent Care centers or the ER.  I anticipate a large increase in late diagnoses in multiple cancers, unless this situation can be addressed, ERs alerted, and more imaging provided for those patients. 


    Peggy Zuckerman

  • 3.  RE: Diagnostic Error in Emergency Medicine - AHRQ Evidence Review

    Posted 03-14-2022 16:41


    The paper also has some concerning blind spots when it comes to pediatric ED patients. For example, necrotizing enterocolitis is a disease primarily of premature neonates. This is not a condition that is at major risk of misdiagnosis in the ED. On the other hand, child abuse is. There is ample evidence that delayed diagnosis of child maltreatment and missed sentinel injuries is associated with more severe presentations later on. But these cases will almost NEVER end up in a malpractice case because of the inherent deceit in the diagnostic process on the part of caregivers (most child abuse is suffered in the home from family members and close contacts). Also, children, with fewer comorbidities, are less likely to suffer permanent harm resulting in lawsuits so they will be underrepresented in malpractice claims data. AHRQ, because of using skewed data, will perpetuate the existing de-prioritization of pediatric diagnostic error research because, as stated in the draft, they don't sue in the same numbers or have the same volume of bad outcomes – this is directly the result of using a non-representative, numerator only sample to define the problem for kids.  





    The paper, at one point, acknowledges that the primary decision in the ED is the safe disposition of the patient rather than definitive diagnosis. While I appreciate that we would all like patients to get diagnosed correctly on their first (or second) visit to the ED, emergency medicine is about identifying and treating immediate life/limb-threatening conditions or those likely to become so imminently.


    Yes, we can get just about any study/imaging test/consult needed rather quickly but that is not necessarily an appropriate use of resources in the ED. And all ED clinicians realize that many patients do not have a primary care provider to follow-up with. But shifting the responsibility of making timely diagnoses to the ED just because they have the resources and the patient in front of them is not an appropriate solution. We lack the ability to effectively follow-up with the patient and we risk overdiagnosis which is an equally insidious and harder to measure problem. We need work on diagnosing emergent conditions like strokes, MIs, sepsis, etc. We are already screening for many diseases like depression, STIs, trafficking, domestic violence and child abuse). Piling on more things for us to manage will not reduce diagnostic errors and runs the risk of diverting our attention from the patients most in need of it (the patient with sepsis, stroke, MIs etc). But expecting EDs to pick up on every indolent slowly progressing life-threatening disease is unfeasible and would also likely be very costly. A better solution is to address the lack of access to care that disproportionately affects the poor and people of color.




    Joe Grubenhoff, MD, MSCS (he/him/his) | Associate Professor of Pediatrics 

    Section of Emergency Medicine | University of Colorado

    Medical Director – Diagnostic Safety Program

    Children's Hospital Colorado

    13123 East 16th Avenue, Box 251  |  Anschutz Medical Campus  |  Aurora, CO 80045 | Phone: (303) 724-2581 | Fax: (720) 777-7317


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  • 4.  RE: Diagnostic Error in Emergency Medicine - AHRQ Evidence Review

    Posted 03-13-2022 17:28
    Thanks for sharing this. However, any study that uses malpractice claims as a measure of diagnostic error needs to acknowledge the inherent structural racism / bias in the data.
    The poor, persons of color, and undocumented immigrants are unlikely to file a lawsuit, and may ironically, be those most likely to be the victim of a misdiagnosis.

    Denise Bockwoldt, PhD, APRN