Learning Objectives: After participating in this activity, the physician should be better able to:
1. Create strategies to avoid potential breakdowns in the diagnostic process that may lead to missed and delayed diagnoses in the ED.
2. Devise a protocol for routinely disclosing medical errors to patients in the ED.
3. Design methods to assess patient capacity and create tactics to prevent refusal of care and improve communication between physicians and patients.
Articles from 2009 Reading List
Missed and Delayed Diagnoses in the Emergency Department: A Study of Closed Malpractice Claims from 4 Liability Insurers
Kachalia A, et al
Ann Emerg Med
Medical errors in the emergency department are an important patient safety concern; as many as 98,000 people die in hospitals each year as a result of medical errors that could have been prevented, according to the Institute of Medicine. (To Err is Human. Washington, DC: National Academy Press; 2000.) Little is known about their cause or prevention. This article reviewed 122 closed malpractice claims to identify the types and causes of diagnostic errors in the emergency department. Of the 122 cases, 79 were chosen for in-depth analysis because of bad outcomes, including 48 percent that led to serious harm and 39 percent that resulted in death.
According to the article, the leading breakdown in the diagnostic process was failure to order an appropriate diagnostic test (58%), failure to perform an adequate medical history or physical exam (42%), and incorrect interpretation of a diagnostic test (37%). The types of missed diagnoses were fractures (19%), infections (15%), myocardial infarction (10%), and cancer (9%). Failure to order radiographs was the most frequently missed diagnostic test (22%), followed by CT scans (17%), cardiac enzymes (15%), ultrasound (13%), and hematologic laboratory tests (11%). According to the article, clinicians failed to order tests because they did not know they were needed (93%) or they did not know they were indicated (52%). To avoid missed and delayed diagnoses in the ED, EPs must create strategies such as alerts to cue providers when using electronic medical records or checklists for differential diagnoses.
Misinterpretations of test results were due to medical judgment (62%) and inexperience (24%). Leading contributing factors were mistakes in judgment (87%), lack of technical competence or knowledge (58%), and lapse in vigilance or memory (41%). Ninety-six percent of missed diagnoses involved at least one of these “cognitive” factors. The other implicated factors were patient-related ones (34%), poor supervision (30%), inadequate sign-outs (24%), and excessive workload (23%).
This study has several very important limitations, primarily because only malpractice claim files were reviewed. That makes it difficult to generalize these findings to the majority of ED cases, which are never brought up on malpractice claims. These case reviews also were not done by emergency physician peers. Each in-depth case analysis was performed by attending physicians, fellows, or third-year residents in internal medicine. There was only limited secondary review by one board certified emergency physician. And perhaps most importantly, reviewers were not blinded to the clinical outcome (outcome bias) or the fact that a claim had been filed. To fairly assess a physician's medical decision-making, the reviewing physician must know only what the physician knew at the time the decision was made.
Emergency Physicians and Disclosure of Medical Errors
Moskop JC, et al
Ann Emerg Med
Medical errors became an important national issue with the publication of the 2000 Institute of Medicine report, To Err is Human. (Washington, DC: National Academy Press; 2000.) One recent study from an academic emergency department identified 18 errors per 100 ED patients, and in 2003, ACEP developed a new policy statement titled, “Disclosure of Medical Errors,” which directs emergency physicians to inform the patient promptly about the error and its consequences. (ACEP Policy Statement, September 2003; http://www.acep.org/practres.aspx?id=29178.) The Institute of Medicine defines a medical error as “the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.” Medical errors often result in harm to patients, but it is important to recognize that not all errors lead to patient harm.
Truthfulness is recognized as a central professional and ethical responsibility of physicians. The AMA in its “Principles of Medical Ethics” states that “a physician shall…be honest in all professional interactions.” Open and honest communication between physicians and patients is essential to foster trust and ensure a successful therapeutic relationship.
One accepted legal standard refers to the concept of a “reasonable person,” proposing that the physician should disclose what a reasonable person would want to know to make an intelligent and informed treatment decision. The majority of patients want to be informed of any errors, including those not resulting in any harm, but emergency physicians must take steps to eliminate many of the obstacles that lie in the path of medical error disclosure:
System barriers: In many institutions, it is often the risk managers who must disclose the error. The ED environment (i.e., high anxiety, high volume, limited encounters with patients) makes it difficult to communicate errors, and it may be difficult to contact the patient after discharge. The patient's condition also may limit disclosures (intoxicated, confused) as do language and cultural differences. Emergency physicians can work toward refining their communications skills and ensure that contact information is obtained during the initial patient visit.
Physician barriers: Lack of training in communication skills and medical errors create a sense of failure in the physician.
Legal barriers: Physicians may be afraid of medical malpractice liability.
Joint Commission standards require that patients and families be informed about unanticipated outcomes of care, including those caused by medical errors. The patient and family should be informed that the problem is being investigated, that information will be given to them when the cause is discovered, and that charges incurred because of the error will be waived.
Refusal of Care: The Physician-Patient Relationship and Decision-Making Capacity
Annal of Emerg Med
Some of the most difficult problems to resolve in the ED are those involving refusal of care. In these situations, we are often forced to weigh our duty to help patients against our obligation to respect their autonomy. Quite often the approach to these cases consists primarily in assessing the patient's decision-making capacity. A patient who is competent to make decisions is discharged against medical advice, while the patient who lacks capacity is treated against his will. Purely focusing on this dichotomy, however, obscures understanding and the ability to address the patient's underlying reason for refusal of care.
In fact, in the majority of cases of refusal of care, the problem is not a lack of capacity but a shortage of communication: Either the patient does not understand the physician or the physician does not understand the patient. When lack of capacity is self-evident, then we must look for a surrogate decision-maker. Optimally in practice, communication and capacity assessment should occur simultaneously. Our goal should be to prevent intractable conflict rather than resolving it through capacity determinations.
This article states that most cases of refusal of care are a result of poor communication and that clear communication and trust in the physician-patient relationship are essential components in preventing this outcome. Physicians can enhance trust by communicating clearly, in terms that the patient can understand, and by paying close attention to patients' needs with empathy and patience. When negotiations become necessary, then all options should be considered, not just the optimum plan of care. It is important to involve the family and friends in the decision-making process. If no compromise can be achieved, then the determination of capacity becomes crucial.
According to “Making Health Care Decisions,” a report by the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research (U.S. Government Printing Office, 1982), decision-making capacity is comprised of possessing a set of values and goals, the ability to communicate and to understand information, and the ability to reason and deliberate about one's choices. When assessing decision-making capacity, the patient should be given all relevant information about his current condition along with treatment plans and alternatives, with the goal of making an informed decision. Extra care should be taken not to exaggerate or underplay any risks or benefits. The patient should be asked to paraphrase and reiterate his understanding of the situation, which often leads to another opportunity for clarification. Finally, if not already evident, the patient should be asked about the reasoning for his decision, which can often expose a patient's inability to make a rational decision.
If a patient lacks capacity, it is reasonable to seek information from advance directives or a surrogate decision-maker. It also may be wise to seek an ethics or risk management consultation when available. If these options do not exist or if there is no time, only then should the physician act as the decision-maker.
Luis M. Lovato, MD, an Associate Clinical Professor at the David Geffen School of Medicine at UCLA, the Director of Critical Care in the Department of Emergency Medicine at Olive View-UCLA Medical Center, and the Medical Editor of www.emcme.com, serves as the medical editor of this column.
CME Participation Instructions
To earn CME credit, you must read the article in Emergency Medicine News, and complete the evaluation questions and quiz, answering at least 80 percent of the questions correctly. Mail the completed quiz with your check for $12 payable to Lippincott Continuing Medical Education Institute, 530 Walnut Street, 8th Floor East, Philadelphia, PA 19106. Only the first entry will be considered for credit, and must be received by Lippincott Continuing Medical Education Institute by December 31, 2010. Acknowledgment will be sent to you within six to eight weeks of participation.
Lippincott Continuing Medical Education Institute is accredited by the Accreditation Council for Continuing Medical Education to provide medical education to physicians. Lippincott Continuing Medical Education Institute designates this educational activity for a maximum of 1 AMA PRA Category 1 Credit.™ Physicians should only claim credit commensurate with the extent of their participation in the activities.