Errors in Diagnosis of Spinal Epidural Abscesses in the Era of Electronic Health Records

Bhise, Viraj; Meyer, Ashley N. D.; Singh, Hardeep; Li, Wei; Russo, Elise; Al-Mutairi, Aymer; Murphy, Daniel R.

doi:10.1016/j.amjmed.2017.03.009

Cited by 38 publications

(41 citation statements)

References 48 publications

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“…One should remember when interpreting our findings that although the rate of potential misdiagnosis-related harm of the serious neurologic conditions we considered is likely relatively high, 8,51 the absolute risk of potential harm for a common, nonspecific symptom presentation is relatively low 52 because the majority of cases are not due to dangerous diseases and because not all missed diagnoses result in harm to patients. Headache and back pain are common complaints in the ED: 2% 39 and 3% 53 of chief complaints, respectively.…”

Section: Discussionmentioning

confidence: 90%

Missed Serious Neurologic Conditions in Emergency Department Patients Discharged With Nonspecific Diagnoses of Headache or Back Pain

Dubosh

Edlow

Goto

et al. 2019

Annals of Emergency Medicine

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Twitter: @ndubosh.Study objective: Serious neurologic conditions can be missed on initial emergency department (ED) visit and discharge diagnosis oftentimes remains a nonspecific symptom. We aim to examine the incidence of potential harm from serious neurologic conditions in ED patients discharged with a nonspecific diagnosis of headache or back pain, identify specific missed conditions, and determine risk factors for potential misdiagnosis-related harm.Methods: This was a retrospective analysis using the population-based data of 6 US states from the State Emergency Department Databases and State Inpatient Databases from 2006 through 2012. We identified adults (18 years) discharged from the ED with a diagnosis of atraumatic headache or back pain. The primary outcome was a composite of return ED visit and hospitalization for primary diagnosis of a serious neurologic condition or inhospital death within 30 days of ED discharge.Results: There were 2,101,081 ED discharges with a nonspecific diagnosis of headache and 1,381,614 discharges with a nonspecific diagnosis of back pain. Overall, 0.5% of the headache patients and 0.2% of back pain patients had a primary outcome. The most common missed condition for headache was ischemic stroke (18.1%). The most common missed condition for back pain was intraspinal abscess (41%). In both populations, advanced age, male sex, non-Hispanic white, and comorbidities (eg, neurologic disorders, HIV/AIDS, malignancy) were associated with higher odds of outcome.Conclusion: A small proportion of ED patients discharged with nonspecific diagnoses of headache or back pain returned with a serious neurologic condition or inhospital death within 30 days.

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Section: Discussionmentioning

confidence: 90%

Missed Serious Neurologic Conditions in Emergency Department Patients Discharged With Nonspecific Diagnoses of Headache or Back Pain

Dubosh

Edlow

Goto

et al. 2019

Annals of Emergency Medicine

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“…12 Therefore, it is crucial to identify causes of diagnostic error and define strategies to improve diagnostic accuracy to achieve a better clinical outcome. [13][14][15] Diagnostic errors are especially a problem in rare diseases. 16,17 These diseases are usually underdiagnosed or mislabeled as a more frequently encountered disease.…”

Section: Discussionmentioning

confidence: 99%

Diagnostic Errors in Initial Misdiagnosis of Optic Nerve Sheath Meningiomas

et al. 2019

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IMPORTANCE Diagnostic errors can lead to the initial misdiagnosis of optic nerve sheath meningiomas (ONSM), which can lead to vision loss. OBJECTIVE To identify factors contributing to the initial misdiagnosis of ONSM. DESIGN, SETTING, AND PARTICIPANTS We retrospectively reviewed 35 of 39 patients with unilateral ONSM (89.7%) who were seen in the tertiary neuro-ophthalmology practice at Emory University School of Medicine between January 2002 and March 2017. The Diagnosis Error Evaluation and Research taxonomy tool was applied to cases with missed/delayed diagnoses. EXPOSURES Evaluation in a neuro-ophthalmology clinic. MAIN OUTCOMES AND MEASURES Identifying the cause of diagnostic errors for patients who initially received a misdiagnosis who were found to have ONSM. RESULTS Of 35 patients with unilateral ONSM (30 women [85.7%]; mean [SD] age, 45.26 [15.73] years), 25 (71%) had a diagnosis delayed for a mean (SD) of 62.60 (89.26) months. The most common diagnostic error (19 of 25 [76%]) was clinician assessment failure (errors in hypothesis generation and weighing), followed by errors in diagnostic testing (15 of 25 [60%]). The most common initial misdiagnosis was optic neuritis (12 of 25 [48%]), followed by the failure to recognize optic neuropathy in patients with ocular disorders. Five patients who received a misdiagnosis (20%) underwent unnecessary lumbar puncture, 12 patients (48%) unnecessary laboratory tests, and 6 patients (24%) unnecessary steroid treatment. Among the 16 patients who initially received a misdiagnosis that was later correctly diagnosed at our institution, 11 (68.8%) had prior magnetic resonance imaging (MRI) results that were read as healthy; 5 (45.5%) showed ONSM but were misread by a non-neuroradiologist and 6 (54.5%) were performed incorrectly (no orbital sequence or contrast). Sixteen of the 25 patients (64%) had a poor visual outcome. CONCLUSIONS AND RELEVANCE Biased preestablished diagnoses, inaccurate funduscopic examinations, a failure to order the correct test (MRI brain/orbits with contrast), and a failure to correctly interpret MRI results were the most common sources of diagnostic errors and delayed diagnosis with worse visual outcomes and increased cost (more visits and tests). Easier access to neuro-ophthalmologists, improved diagnostic strategies, and education regarding neuroimaging should help prevent diagnostic errors.

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“…Although chart review is often considered the standard to study diagnostic errors and delays, it has several limitations because written documentation might not accurately represent all aspects of a patient encounter. However, previous studies have shown good consistency between what is documented in the EHR and actual practice . Despite our attempts to improve reliability, the kappa for agreement between our chart reviewers was not in the “excellent” range.…”

Section: Discussionmentioning

confidence: 69%

Electronic health record reviews to measure diagnostic uncertainty in primary care

Bhise

Rajan

Sittig

et al. 2018

Evaluation Clinical Practice

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Errors in Diagnosis of Spinal Epidural Abscesses in the Era of Electronic Health Records

Cited by 38 publications

References 48 publications

Missed Serious Neurologic Conditions in Emergency Department Patients Discharged With Nonspecific Diagnoses of Headache or Back Pain

Missed Serious Neurologic Conditions in Emergency Department Patients Discharged With Nonspecific Diagnoses of Headache or Back Pain

Diagnostic Errors in Initial Misdiagnosis of Optic Nerve Sheath Meningiomas

Electronic health record reviews to measure diagnostic uncertainty in primary care

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