Apr 24, 2016
A recent study in the Journal Stroke highlights many of the recurring themes in patient safety and diagnostic errors. The study identified missed strokes at both academic medical centers and community hospitals. The rates were alarmingly high, approximately 25% were missed and data analysis revealed most were in the posterior circulation and presented with nonspecific or atypical symptoms. The young were disproportionately affected. Both institutions studied had certified stroke programs.
The results are particularly concerning since early stroke intervention has been shown to mitigate long-term disability and more treatments for stroke in the acute setting are available. Approximately 50% of the missed strokes presented within the time frame for intervention.
The recent NAM report highlighting the prevalence of diagnostic errors as a major safety and quality concern in health care is once again demonstrated in the study.
Should we conclude that atypical or nonspecific symptoms ( nausea/ vomiting, headache and dizziness) in young patients are predictably going to lead to misdiagnosis. Probably yes, but the troubling aspect of the study is the well described pattern of type one thinking, anchoring on an initial diagnosis and ignoring countervailing evidence (confirmation bias). The inherent bias and behavioral psychology patterns which compromise our analytic process once again are evident. We do not know what we do not know and we stay within our comfort zones.
The absence of the evaluation by a neurologist was pointed out as problematic but no discussion of telemedicine availability was suggested as a remedy.
Most troubling in the study was the revelation that
In our data, there was no documented NIHSS score
or neurology examination in a significant proportion of missed
strokes. If a primary neurological event is not considered, then
a thorough neurological examination may not be performed.
A proportion of the missed strokes may have been identified if
a neurological examination was done. Completing a systematic
review of systems and examination is a fast, cost-effective
way to ensure that neurological findings are not being missed.
The basic principle of taking a complete history including doing a review of symptoms and complete physical exam was ignored! Also concerning is the fact the study did not address the number of patients sent home with stroke who were not included in the study.
There are clear interventions that can address the troubling results of the study. Every patient must have a complete history and physical (H&P) especially those with nonspecific symptoms. While obtaining an H&P is a fundamental tenet of all medical care, especially in an ER setting where acuity and complexity of patients is high, it is tragic that this reminder is needed. Neurologic consultation using telemedicine should be made available. Probably most important is the need for electronic/clinical decision support software which highlights the broad range of differential diagnostic possibilities for non specific symptoms and especially brings to the attention of the physician the high risk diagnosis which one cannot afford to miss. Lastly educating patients about the problem of errant diagnosis and the need to be sure that all their symptoms especially if persistent are addressed can only help to remind caregivers of the need to be thorough. Always asking "But doctor could it be anything else?" may save lives.
Nicolas Argy, M.D., J.D. Health/Business Consultant/Educator, Patient Safety, Quality, Risk Management, Public Health Advocate, Witness Prep