Electronic health record-based surveillance of diagnostic errors in primary care

Abstract

Background Diagnostic errors in primary care are harmful but difficult to detect. We tested an electronic health record (EHR)-based method to detect diagnostic errors in routine primary care practice. Methods We conducted a retrospective study of primary care visit records “triggered” through electronic queries for possible evidence of diagnostic errors: Trigger 1: A primary care index visit followed by unplanned hospitalization within 14 days; and Trigger 2: A primary care index visit followed by ≥ 1 unscheduled visit(s) within 14 days. Control visits met neither criterion. Electronic trigger queries were applied to EHR repositories at two large healthcare systems between October 1, 2006 and September 30, 2007. Blinded physician-reviewers independently determined presence or absence of diagnostic errors in selected triggered and control visits. An error was defined as a missed opportunity to make or pursue the correct diagnosis when adequate data was available at the index visit. Disagreements were resolved by an independent third reviewer. Results Queries were applied to 212,165 visits. On record review, we found diagnostic errors in 141 of 674 Trigger 1-positive records (PPV=20.9%, 95% CI, 17.9%-24.0%) and 36 of 669 Trigger 2-positive records (PPV=5.4%, 95% CI, 3.7%-7.1%). The control PPV of 2.1% (95% CI, 0.1%-3.3%) was significantly lower than that of both triggers (P ≤ .002). Inter-rater reliability was modest, though higher than in comparable previous studies (κ = 0.37 [95% CI=0.31-0.44]). Conclusions While physician agreement on diagnostic error remains low, an EHR-facilitated surveillance methodology could be useful for gaining insight into the origin of these errors.

Patient safety in primary health care: a systematic review

“…There was a balance in the yearly distribution of the articles' publication: four in 2007 9,10,11,12 , six in 2008 13,14,15,16,17,18 , three in 2009 19,20,21 , ten in 2010 22,23,24,25,26,27,28,29,30,31 , six in 2011 32,33,34,35,36,37 and four in 2012 38,39,40,41 (Table 2).…”

“…The study population consisted of physicians and other health professionals 9,10,13,14,15,16,19,20,22,24,25,28,30,32,33,34,35,36,39,40 , patients and families 26 , and health professionals and patients and families 11,21,23,27,29,31,41 , while in some studies the study population was not described in complete detail 17,22,38 (Table 2).…”

“…All the studies were descriptive. Nine studies were retrospective 9,13,14,15,18,19,32,37,38 , 14 prospective 10,16,20,22, 23,24,25,26,27,28,33,34,39,40 , and ten cross-sectional 11,12,17,21,29,30,31,35,36,41 .…”

“…Other studies used a combination of methods for data sources: incident reporting systems, direct observation, and focus groups 35 ; incident reporting systems, direct observation, and interviews 11 ; direct observation with audio recording 29 ; direct observation and expert consensus 36 ; incident reporting systems, patient file review, and interviews 41 ; incident reporting systems and patient file review 21 ; incident reporting systems, interviews, and questionnaires 30 ; expert consensus, questionnaires for patients, and focus groups 31 ; incident reporting systems, patient file review, and questionnaires 41 (Table 2). Six studies 12,17,21,30,31,41 used a combination of data sources. Reporting system were the most frequent data source: 15 studies (45%) 9,11,12,13,14,15,18,19,21,30,32,35,37,38,41 .…”

“…Six studies 12,17,21,30,31,41 used a combination of data sources. Reporting system were the most frequent data source: 15 studies (45%) 9,11,12,13,14,15,18,19,21,30,32,35,37,38,41 . The definition of adverse events differed, while the great majority of studies did not present a definition for these events.…”