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Doctors like everyone else make mistakes

Steven E. North, Esq.
Jason Persaud, Paralegal

Doctors like everyone else make mistakes. However, their mistakes can make the difference between life and death or permanent injury.

And those mistakes not only affect the patient's health, but also have significant financial impact due to additional medical treatment or the costs associated with medical malpractice litigation. Since the impact of medical mistakes has significant implications, it is useful to identify the common mistakes that are made and to try to find out how they can be prevented or reduced. Once the errors identified, better treatment protocols can be developed to limit the damage.

This subject was discussed in the Wall Street Journal on September 26, 2015,"A Medical Detective Story: Why Doctors Make Diagnostic Errors". The author, Dr. Singh, chief at the Michael E. De Bakey VA Medical Center in Houston, investigated the impact of diagnostic errors and how technology can help healthcare providers avoid making them.

Dr. Singh found that an estimated 5% of patients or 12 million American adults are misdiagnosed every year. One in twenty American adults will experience misdiagnosis.The most commonly missed diagnoses are pneumonia, heart failure, kidney failure, cancer and urinary tract infections. Looking at these illnesses, it is understandable why a prompt diagnosis is critical. Failure to timely diagnose cancer for example, would likely allow progression of the disease and a poorer prognosis for the patient. Failure to diagnose heart disease can lead to a heart attack with irreversible damage to the patient's heart requiring extensive surgeries and ultimate transplantation. The importance of error prevention is should be clear.

The study found that proper diagnoses were either completely missed or delayed. Some of the common threads found were failing to properly interpret history and physical exam findings at primary-care clinics. By examining the medical records of outpatient visits it was apparent that there was not sufficient time dedicated to patient care. Consequently the failure to arrive at the proper differential diagnosis was due to the inability of the clinical physician to obtain sufficient information. Conditions with non-specific symptoms that require follow up attention to arrive at a diagnosis are often missed.It is apparent that less time spent with patients means less information is obtained for the doctor which allows for subtle nuances to be overlooked.

The solution may partly be found with the use of electronics to help obtain more accurate diagnoses. Electronic records offer doctors instant access to a patient's complete medical history, eliminating the wait for often incomplete paper records to be transferred from provider to provider. For those who present with emergent symptoms, immediate access to the patient's medical chart can be life-saving.

Electronic medical records allow fora "trigger" system which involves the placement in the chart of red flags where there are abnormal findings. These triggers remain in the chart to ensure proper follow up and attention. It assures that the treating physician remains aware of an abnormal condition and allows for the monitoring of a benign condition that may become dangerous if not properly managed.

Medical diagnostic errors have been the subject of ongoing attention."The Biggest Mistake Doctors Make", published in the Wall Street Journal on November 17, 2013 discusses the harmful and costly effects of medical mistakes. It was noted that diagnostic errors are more common than other medical mistakes and are the most preventable.Non-diagnostic errors, such as an inadvertent injury during surgery are more difficult to prevent than a condition that progresses over time and allows providers multiple opportunities to identify and treat it before damage occurs.

The article notes that health care providers are now looking toward a number of innovative strategies to prevent medical errors. It also emphasizes the utilization of electronic medical records. Electronic medical can be made readily accessible to healthcare providers, regardless of differences in hospital affiliation or provider location.

Some institutions are surveying their electronic records to proactively look for potential errors. The article makes reference to the Southern California Permanente Medical Group, where a case manager reviewed 8,076 patient's records that reported abnormal PSA test results. More than 25% of those patients had follow up biopsies. Among those patients, 745 cancers were diagnosed during that time period from 2006 through 2009 and there were no malpractice claims related to missed PSA tests. The same facility also reviewed patients with abnormal creatinine values to assess kidney disease. They found that from 2007 through 2012, there were 7,218 lab orders for repeat testing were not performed. Of those, 3,465 patients who had repeat testing within 90 days of notice, 1,624 were discovered to have kidney disease.

Given the success of the Permanent Medical Group project, it is apparent that proactively reviewing medical records can lead to correctly diagnosing conditions which might otherwise slip through the cracks. Consequently, monitoring the medical records of patients who have borderline lab test results for disease or require further testing will lead to follow-up studies that will identify the ongoing process. With the assistance of electronic medical records monitoring, medical charts are more easily examined and patient call-back notices issued.

Another advantage of electronic medical records is that they are usually more organized and easier to navigate than paper charts. The electronic database separates medical records into various categories such as progress notes, laboratory results, radiology results so that information can easily be accessed. Information is available at "the push of a button." Utilizing features such as a "word search" in an electronic database instead of manually sifting through a large stack of records make the ability to access a patient's critical lab data or other information easier than ever.

The article acknowledges that many doctors are overburdened and do not have sufficient time to properly examine patients, order tests and follow up with patients. The solution may not be to flood doctors with information, but to offer a second set of eyes, via computer. Building upon the use of electronic medical records, healthcare providers are encouraged to "flag" certain abnormalities in patients within their electronic records. These flags will remind providers to follow up with patients and will highlight the abnormality each time the patient's records are accessed by any provider who can then see if follow up testing or treatment is needed.

Another suggestion to avoid medical errors is to broaden the doctor's thinking and reasoning when evaluating a patient. Doctors are now being trained to keep an open mind and not focus on a single diagnosis. When confronted with vague or conflicting evidence, doctors must be able to form differential diagnoses and consider all possibilities, ruling out the most serious ones first. If the focus is only on a single diagnosis, another condition may go undiagnosed and worsen.

One tool that is currently being developed is an electronic decision support program which help doctors rank possible diagnoses based on the notes and symptoms in the medical records. The article makes reference to one such system name Isabel, which was able to correctly diagnose 96% of 50 challenging cases. Though this technology seems to be going in the right direction, these tools should be intended to assist healthcare providers and not replace them.

Another practice that may reduce medical errors may not be the responsibility of the medical professional, rather of the patient. Patients can facilitate their care by providing a written history timeline and list of current problems to assist their physicians. This information may help reduce the risk of missing important diagnostic questions. Another aid in medical evaluations is to encourage patients to ask questions and not to feel rushed or intimidated by the doctor. By asking questions the physician-patient relationship is enhanced and may lead to a fuller understanding of the patient's problem.

Patients have the responsibility of being active regarding their healthcare. Promptly following up with appointments eliminates the need for physicians to have to "chase" patients to keep important appointments or fall through the cracks. Patients should keep their healthcare providers informed of any changes in their health. Health care proxies and living wills are instruments that patients should consider and provide copies to their primary care physicians.

Medical errors are a big problem, impacting both patients' health and the economy. "The $17.1 Billion Problem: The Annual Cost of Measurable Medical Errors" published in Health Affairs in April, 2011, reports that in 2008, the estimated annual cost of measurable medical errors that harm patients was $17.1 Billion dollars. "A New, Evidence-based Estimate of Patient Harms Associated with Hospital Care" published in the Journal of Patient Safety in September, 2013 claims that over 400,000 people die annually from preventable hospital error, putting it as the third leading cause of death in the United States. While considering the most effective error prevention methods, we find a few key elements: further education on medical error prevention; communication with both health care providers and patients; and modern technology. Focusing on these very manageable issues can reduce the number of errors and result in decreasing both the injury to patients and excessive medical costs.

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Laurence M. Deutsch

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