Douglas Noble: Patient safety – diagnostic errors

douglas nobleLast week I fell onto an outstretched hand and clinically had an obvious fracture on the ulnar side of my left wrist.  Interestingly, the very diligent nurse practitioner who examined me became fixated on my scaphoid – having pushed extraordinarily hard in the anatomical snuffbox and eliciting pain.  Scaphoid views were requested and no fracture seen.  I expressed concern that perhaps the fracture was elsewhere, but was promptly told: ‘chances can’t be taken with the scaphoid’.  I was bundled into a futura splint, given a photocopy of my notes, instructions to return ten days later and shown the door.  I couldn’t help but read the notes the minute I walked out of A+E.  F.R.O.M. (full range of movement) dutifully scribed (almost everywhere); surprised me as I couldn’t move it even slightly.After fracture clinic review today re-Xrays have shown a fractured lunate.  I’m feeling sorry for myself, and my experience is minor, but it reminded me about the importance of diagnostic errors in patient safety.

Diagnostic errors have not been considered a cornerstone of current patient safety thinking.  Yet, recent studies indicate that these account for 15% of all adverse events in hospital.  This may be of no real surprise, but, as patient safety has steered away from criticizing individuals, this might represent an area of neglect to re-focus upon.

A common contributing factor is first diagnosis syndrome (as above).  In addition to too quickly abandoning the rational process of differential diagnosis and jumping to conclusions, this is also frequently aided by the reams of informal information handover sheets circulating between clinical teams.  These are at their most dangerous when dutifully photocopied on post-take rounds.  Often they contain small boxes with a simple label: diagnosis.  This can be filled in by the A+E nurse or casualty officer and then amended by the admitting team.  It typically reads anything from woozy to urinary sepsis.  I’ve seen post-take consultants focus on these intently as they march purposefully to the next ward.  In fact, I’ve rarely seen it significantly changed.

Shortness of time syndrome, and occasionally, got to get to the private clinic syndrome also contribute faithfully to diagnostic errors.  The lethal synergy of a ward-based admitting system (which sees patients fielded out to different wards within 4 hours of arrival) and coming under a different named consultant further heightens the symptoms.  The post-take consultant need not bother too much (especially for non-life threatening cases) as someone else will refine the diagnosis at a later stage, probably.  Medical post-take rounds can finally be conducted faster than surgical ones.  Urinary sepsis becomes a unifying diagnosis for most patients.  MSU results are frightening:  negative, negative, negative!

Douglas Noble has worked in surgery, emergency medicine, public health and for WHO Patient Safety. From 2006 to 2008 he was clinical adviser to chief medical officer for England, Sir Liam Donaldson.

  • Iain Yardley

    Isn’t it called a “set” or “group think” when a group of people all think the same thing and persuade them selves that it is right?

    Given that diagnosis is what fundamentally sets doctors apart from other health care workers it is worrying but perhaps not surprising that they are reluctant to review or change them once made.

  • Correct diagnosis and differential diagnoses are things in the past.
    What often happens nowadays is that the patient must somehow fit the doctor’s diagnosis, decided upon after the first sentences uttered by the patient/carer and a slip-shod examination.
    What seems to be topmost is ‘arrive at some/any diagnosis’ and start the management and treatment a.s.a.p.regardless

  • Eugenia Lee

    Whilst the government is keen on keeping the admirable intention of increasing access to doctors at all times, as and when you need, where you think it’s convenient, we are seeing a sea of patient who has booked for a consultation for ‘runny nose for 3 hours’, ‘vomiting x1 3d ago’ or ‘Johnny had a temperature last night, completely well now but we thought we will get him checked’ in the midst of the pathologies that actually need addressing in between patients who ‘I do not want to waste your time doc’ syndrome when they have been unwell for a long period of time.

    We are all working hard to keep up our clinical accruement in the midst of self-limiting illness who present so early in the course of the illness that I give advice the patients already know far too well or false reassurances if the illness turns for the worse later on when a diagnosis of ‘viral illness’ vaguely describes the actual clinical process whilst we wait and see what happens…

  • John

    As a new f1 I have already kicked myself several times over missed diagnoses – the syndome for us is one of being busy with menial but essential administrative tasks and going along with senior diagnoses that you have serious doubs about because, well, they are senior and you think “I must have missed something back there”.
    However if you ask the right question in the right way you can make your consultant/reg think they came up with the retrospectively obvious diagnosis/test and so avoid having to appear to correct them!

  • RG

    Somehow the new system, EWTD are not helping this as well. Gone are the days when a patinent was follwoed by the admitting team to discharge and the junior doctors could see the whole process of diagnosis, challnging the differential diagnosis, revising the initian diagnosis before coming to a final diagnosis and discharging the patient.

    The post take ward round works both ways.WHilst there is a tendency to complete the post take ward round in time to “get on with rest of the day syndrome” juniors also do not wish to stay longer than they have to. Presnetation is not efficient, most of the time it starts with ” this patient has UTI”. Is is because we are not training our juniors correctly or do we sense some reluctance in them and feel an attitude of “just finish the call”
    End results is delayed discharges, longer hospital stays and higher readmission rate… exactly opposite of what the giovernment want us to do.. so what shall we do.. opt out of EWTD so that training gets mpore focused or rejuggle the rotas so that the admitting team complete the post take ward round or get back to the old “team based system”

    I still fail to understand why ward based system should be operational if it is impacting on the training of the future generation of doctors?
    Because the A/E doctor does not see that what he thought wasa scaphoid in fact was a lunate facture, poor yooung doctor would continue to make the same mistake again and again.

    Do we need another Lord to bring back the “team based system” and dispense with the ward based system? If it improves patinets life and doctors training: so be it. Are you listening Mr Liam Donaldson or Mr Millburn or Mr Gordon Brown?