Types of diagnostic errors in neurological emergencies in the emergency department

Abstract

Background: Neurological emergencies often pose diagnostic challenges for emergency physicians because these patients often present with atypical symptoms and standard imaging tests are imperfect. Misdiagnosis occurs due to a variety of errors. These can be classified as knowledge gaps, cognitive errors, and systems-based errors. The goal of this study was to describe these errors through review of quality assurance (QA) records. Methods: This was a retrospective pilot study of patients with neurological emergency diagnoses that were missed or delayed at one urban, tertiary academic emergency department. Cases meeting inclusion criteria were identified through review of QA records. Three emergency physicians independently reviewed each case and determined the type of error that led to the misdiagnosis. Proportions, confidence intervals, and a reliability coefficient were calculated. Results: During the study period, 1168 cases were reviewed. Forty-two cases were found to include a neurological misdiagnosis and twenty-nine were determined to be the result of an error. The distribution of error types was as follows: knowledge gap 45.2% (95% CI 29.2, 62.2), cognitive error 29.0% (95% CI 15.9, 46.8), and systems-based error 25.8% (95% CI 13.5, 43.5). Cerebellar strokes were the most common type of stroke misdiagnosed, accounting for 27.3% of missed strokes. Conclusions: All three error types contributed to the misdiagnosis of neurological emergencies. Misdiagnosis of cerebellar lesions and erroneous radiology resident

Missed Serious Neurologic Conditions in Emergency Department Patients Discharged With Nonspecific Diagnoses of Headache or Back Pain

“…Previous studies on the misdiagnosis of neurologic emergencies have described cognitive errors, knowledge gaps, and systems-based errors as contributing factors. 11,40,57,58 In a recent meta-analysis of 15,721 patients with acute cerebrovascular events, Tarnutzer et al 8 found that misdiagnosis was more frequent for patients presenting with milder, transient, and nonspecific symptoms such as headache and dizziness. These atypical presentations are more prone to cognitive biases and failed heuristics for the physician, and therefore it is important for frontline providers to be aware of them.…”

Feasibility and Reliability Testing of Manual Electronic Health Record Reviews as a Tool for Timely Identification of Diagnostic Error in Patients at Risk

“…Most evidence regarding DE in acutely ill patients comes from retrospective chart review or postmortem studies. [27][28][29] In this article, we explore the reliability of chart review strategies to support real-time recognition of DE risk in acutely ill patients.…”

“…35 The proportion of DE can vary for different populations and settings, and depends on study methodology. 4,[27][28][29] Each review was estimated to take approximately 1 hour per reviewer per patient. This has obvious implications for the scalability and use of this tool outside of our acute care learning laboratory environment.…”

The Level of Knowledge Among Undergraduate Medical Students About Stroke

“…3 Literatur lain melaporkan bahwa dari seluruh kasus kegawatdaruratan neurologis, stroke merupakan penyakit yang paling sering mengalami kesalahan diagnosis yaitu sebesar 37,9%. 4 Pada studi prospektif yang dilakukan oleh Tomi dkk. dari bulan Desember 2014-April 2015 di Instalasi Gawat Darurat (IGD) rumah sakit di Yogyakarta pada pasien stroke, sebesar 98,10% dan 61,30% subjek secara berturutturut mengalami kesalahan pengobatan pada fase peresepan dan fase administrasi.…”

“…Tingginya kejadian pada kelompok knowledge gap disebabkan oleh karena kurangnya edukasi mengenai penyakit yang salah didiagnosis, termasuk penyakit stroke. 4 Studi lain mengenai penyebab kesalahan diagnosis menemukan bahwa faktor kognitif berupa kecacatan dalam memori dan kurangnya pengetahuan atau kompetensi dokter termasuk ke dalam faktor dominan yang berkontribusi. 3 Survei yang dilakukan terhadap dokter Unit Gawat Darurat (UGD) di 24 rumah sakit menunjukan hal serupa, dimana kurangnya familiaritas dokter terhadap pedoman pengobatan stroke menjadi salah satu hambatan untuk mengadministrasikan tissue-Plasminogen Activator (tPA) kepada pasien stroke iskemik akut.…”