Picture of Paras Salva, DO

Paras Salva, DO

Arrowhead Resident & CANS Fellow

Socioeconomic Journal Club

The CANS newsletter will feature a socioeconomic journal club.  We will review articles in the broader policy context, with both a resident and attending providing their perspectives.

This month, we review “Diagnostic Errors in Hospitalized Adults Who Died or Were Transferred to Intensive Care,” from JAMA Internal Medicine.

Paras Salva, DO: Arrowhead Resident & CANS Fellow- Errors in healthcare can occur at any level. The impact of these errors is felt by patients, families, practitioners, and healthcare systems. A recent UCSF study quantified the prevalence of such errors in a retrospective cohort study conducted at 29 academic medical centers across the US, researchers delved into the prevalence, causes, and consequences of diagnostic errors among hospitalized adults. The study focused on those transferred to an intensive care unit (ICU) or those who sadly succumbed to their conditions. A staggering 23.0% of the 2428 patient records reviewed showcased instances of diagnostic errors. These errors, ranging from missed to delayed diagnoses, were found to contribute to temporary harm, permanent harm, or even death in 17.8% of cases. Among the 1863 patients who died, diagnostic errors were identified as a contributing factor in 6.6% of cases.

These findings shed light on a critical aspect of patient safety, emphasizing the need for a closer examination of the diagnostic process. The study pinpointed key areas where diagnostic errors were most prevalent, providing crucial insights for improvement efforts. Patient assessment problems, accounting for 21.4%, and challenges in test ordering and interpretation, at 19.9%, emerged as high-priority targets for reducing diagnostic errors. In addition, the data reveals socioeconomic factors that contribute to higher rates of errors; for example, patients with lack of preferences for care in the diagnostic process (ie. Patients who were not personally invested in their care or had others to assist) or experienced housing instability were more likely to have medical errors.

Where do we go from here? Although this study points out the prevalence of these errors and identifies factors that preclude patients from experiencing these errors, the authors justifiably do not make any claims as to how to fix the issue at hand – a tall task for anyone to accomplish. Additionally, the study focuses only on factors of the patient population that affect their likelihood of experiencing diagnostic errors. The study does not specifically include factors that could affect the practitioner’s ability to correctly diagnose pathology including physician fatigue and burn out, lack of resources leading to social and distributive justice in ordering a broad spectrum of tests, or even lack of an interdisciplinary approach to patient care which has been repeatedly proven to improve outcomes.

The study does provide more description of a critical aspect of healthcare, however. It highlights the need of the healthcare system and all practitioners to continue to adapt and adjust to the never-ending challenges of diagnosing complex medical issues. It also highlights the need to continue working with patients and their families to ensure access to the highest quality of care regardless of socioeconomic status.

Anthony DiGiorgio, DO, MHA: UCSF Attending & CANS Newsletter Editor – Recent publications, including this one, continue to shine light on errors in medical practice. This growing body of literature, ranging from the notable “To Err is Human” to the latest JAMA paper, consistently, and I would say unfairly, highlights the imperfections in medical diagnoses and treatments as a significant source of patient harm. While acknowledging the

reality of human error in medicine, it’s essential to delve deeper into the context and constraints within which these errors occur. 

Physicians are not infallible. We operate within a complex healthcare system, where every decision involves a trade-off. These trade-offs are not solely in the hands of the physicians; they are significantly influenced by policies set by legislators and administrative authorities. It’s crucial to understand that these decisions are made amidst resource limitations and time constraints, far from the idealized scenario where each patient receives unlimited attention and resources.

The JAMA study specifically points out that 23% of unexpected deaths or ICU transfers were attributed to diagnostic errors by physicians. While this statistic is concerning, it undoubtedly evokes skepticism.  We need to dive deeper.

For instance, one case study in the paper describes a delayed diagnosis of Guillain-Barre syndrome, leading to a patient’s cardiac arrest and subsequent death. To the uninitiated, this might seem like a clear oversight. However, those in the field know the challenges of diagnosing spinal pathologies, where symptoms like pain and weakness are common. The reality of limited resources like MRI scans and the need for triage further complicates these decisions. While the goal is always to minimize errors, the inevitability of some degree of diagnostic uncertainty must be acknowledged.  What if the patient had a benign disease and underwent an unnecessary lumbar puncture?  There are tradeoffs in performing tests aside from resource utilization.  False positives and unnecessary procedures have complications as well. 

Moreover, attributing outcomes like cardiac arrest and death solely to diagnostic errors oversimplifies the complexities of medical conditions like Guillain-Barre syndrome, which can have severe consequences even with perfectly timely and accurate diagnosis. It’s a reminder that physicians, despite our expertise and best efforts, cannot always prevent adverse outcomes.  That patient might have died even if the diagnosis was caught immediately.  Just because an error occurred and a patient died doesn’t mean that the error caused the death.

It’s also important to recognize the impact of workload burdens on physicians. With employed physicians asked to do more with fewer resources, our cognitive capacity is stretched ever thinner.  A significant portion of our time is consumed by paperwork and tasks that detract from patient care rather than enhance it. This not only affects the quality of medical decision-making but also contributes to the likelihood of errors.

While striving for excellence and acknowledging errors in medicine is vital, it’s equally important to consider the broader context of healthcare delivery. This includes the challenges of resource allocation, the consequences of diagnostic tests, and the administrative burdens that impact physician decision-making. A more holistic approach to understanding and addressing these issues will not only lead to better patient outcomes but also support physicians in their critical role in healthcare.