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.