Jump to ContentJump to Main Navigation
Show Summary Details
More options …

Diagnosis

Official Journal of the Society to Improve Diagnosis in Medicine (SIDM)

Editor-in-Chief: Graber, Mark L. / Plebani, Mario

Ed. by Argy, Nicolas / Epner, Paul L. / Lippi, Giuseppe / Singhal, Geeta / McDonald, Kathryn / Singh, Hardeep / Newman-Toker, David

Editorial Board: Basso , Daniela / Crock, Carmel / Croskerry, Pat / Dhaliwal, Gurpreet / Ely, John / Giannitsis, Evangelos / Katus, Hugo A. / Laposata, Michael / Lyratzopoulos, Yoryos / Maude, Jason / Sittig, Dean F. / Sonntag, Oswald / Zwaan, Laura


CiteScore 2018: 0.69

SCImago Journal Rank (SJR) 2018: 0.359
Source Normalized Impact per Paper (SNIP) 2018: 0.424

Online
ISSN
2194-802X
See all formats and pricing
More options …

Breakdowns in the initial patient-provider encounter are a frequent source of diagnostic error among ischemic stroke cases included in a large medical malpractice claims database

Ava L. Liberman
  • Corresponding author
  • Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Stern Stroke Center, 3316 Rochambeau Avenue, 4th Floor, Bronx, NY 10467, USA
  • Email
  • Other articles by this author:
  • De Gruyter OnlineGoogle Scholar
/ Jillian Skillings / Penny Greenberg / David E. Newman-Toker
  • Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
  • Departments of Epidemiology and Health Policy and Management, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
  • Email
  • Other articles by this author:
  • De Gruyter OnlineGoogle Scholar
/ Dana Siegal
Published Online: 2019-07-11 | DOI: https://doi.org/10.1515/dx-2019-0031

Abstract

Background

Misdiagnosis of dangerous cerebrovascular disease is a substantial public health problem. We sought to identify and describe breakdowns in the diagnostic process among patients with ischemic stroke to facilitate future improvements in diagnostic accuracy.

Methods

We performed a retrospective, descriptive study of medical malpractice claims housed in the Controlled Risk Insurance Company (CRICO) Strategies Comparative Benchmarking System (CBS) database from 1/1/2006 to 1/1/2016 involving ischemic stroke patients. Baseline claimant demographics, clinical setting, primary allegation category, and outcomes were abstracted. Among cases with a primary diagnosis-related allegation, we detail presenting symptoms and diagnostic breakdowns using CRICO’s proprietary taxonomy.

Results

A total of 478 claims met inclusion criteria; 235 (49.2%) with diagnostic error. Diagnostic errors originated in the emergency department (ED) in 46.4% (n = 109) of cases, outpatient clinic in 27.7% (n = 65), and inpatient setting in 25.1% (n = 59). Across care-settings, the most frequent process breakdown was in the initial patient-provider encounter [76.2% (n = 179 cases)]. Failure to assess, communicate, and respond to ongoing symptoms was the component of the patient-provider encounter most frequently identified as a source of misdiagnosis in the ED. Exclusively non-traditional presenting symptoms occurred in 35.7% (n = 84), mixed traditional and non-traditional symptoms in 30.6% (n = 72), and exclusively traditional in 23.8% (n = 56) of diagnostic error cases.

Conclusions

Among ischemic stroke patients, breakdowns in the initial patient-provider encounter were the most frequent source of diagnostic error. Targeted interventions should focus on the initial diagnostic encounter, particularly for ischemic stroke patients with atypical symptoms.

Keywords: diagnostic error; ischemic stroke; malpractice claims

Subject terms: diagnosis; ischemic stroke; emergency department

References

  • 1.

    National Academies of Sciences E, and Medicine. Improving Diagnosis in Healthcare. Washington, DC: The National Academies Press, 2015.Google Scholar

  • 2.

    Emberson J, Lees KR, Lyden P, Blackwell L, Albers G, Bluhmki E, et al. Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomised trials. Lancet 2014;384:1929–35.PubMedCrossrefWeb of ScienceGoogle Scholar

  • 3.

    Kernan WN, Ovbiagele B, Black HR, Bravata DM, Chimowitz MI, Ezekowitz MD, et al. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2014;45:2160–236.Web of SciencePubMedCrossrefGoogle Scholar

  • 4.

    Newman-Toker DE, Perry JJ. Acute diagnostic neurology: challenges and opportunities. Acad Emerg Med 2015;22:357–61.CrossrefPubMedWeb of ScienceGoogle Scholar

  • 5.

    Saver JL. Time is brain – quantified. Stroke 2006;37:263–6.PubMedCrossrefGoogle Scholar

  • 6.

    Madsen TE, Khoury J, Cadena R, Adeoye O, Alwell KA, Moomaw CJ, et al. Potentially missed diagnosis of ischemic stroke in the emergency department in the Greater Cincinnati/Northern Kentucky Stroke Study. Acad Emerg Med 2016;23:1128–35.CrossrefPubMedWeb of ScienceGoogle Scholar

  • 7.

    Arch AE, Weisman DC, Coca S, Nystrom KV, Wira CR, 3rd, Schindler JL. Missed ischemic stroke diagnosis in the emergency department by emergency medicine and neurology services. Stroke 2016;47:668–73.CrossrefPubMedWeb of ScienceGoogle Scholar

  • 8.

    Richoz B, Hugli O, Dami F, Carron PN, Faouzi M, Michel P. Acute stroke chameleons in a university hospital: risk factors, circumstances, and outcomes. Neurology 2015;85:505–11.Web of ScienceCrossrefGoogle Scholar

  • 9.

    Lever NM, Nystrom KV, Schindler JL, Halliday J, Wira C, 3rd, Funk M. Missed opportunities for recognition of ischemic stroke in the emergency department. J Emerg Nurs 2013;39:434–9.PubMedWeb of ScienceCrossrefGoogle Scholar

  • 10.

    Liberman AL, Prabhakaran S. Stroke chameleons and stroke mimics in the emergency department. Curr Neurol Neurosci Rep 2017;17:15.Web of SciencePubMedCrossrefGoogle Scholar

  • 11.

    Newman-Toker DE, Moy E, Valente E, Coffey R, Hines AL. Missed diagnosis of stroke in the emergency department: a cross-sectional analysis of a large population-based sample. Diagnosis (Berl) 2014;1:155–66.PubMedCrossrefGoogle Scholar

  • 12.

    Holden RJ, Carayon P, Gurses AP, Hoonakker P, Hundt AS, Ozok AA, et al. SEIPS 2.0: a human factors framework for studying and improving the work of healthcare professionals and patients. Ergonomics 2013;56:1669–86.PubMedCrossrefWeb of ScienceGoogle Scholar

  • 13.

    CRICO. The Risk Management Foundation of the Harvard Medical Institutions Incorporated. 2018. https://www.rmf.harvard.edu. Accessed: 26 Dec 2018.

  • 14.

    Tirschwell DL, Longstreth WT, Jr. Validating administrative data in stroke research. Stroke 2002;33:2465–70.PubMedCrossrefGoogle Scholar

  • 15.

    Lisabeth LD, Brown DL, Hughes R, Majersik JJ, Morgenstern LB. Acute stroke symptoms: comparing women and men. Stroke 2009;40:2031–6.CrossrefWeb of SciencePubMedGoogle Scholar

  • 16.

    Millikan CH, Bauer RB, Goldschmidt J, Goldstein M, Heyman A, Meyer JS, et al. A classification and outline of cerebrovascular diseases. II. Stroke. J Cereb Circulation 1975;6:564–616.Google Scholar

  • 17.

    Paul NL, Simoni M, Rothwell PM, Oxford Vascular S. Transient isolated brainstem symptoms preceding posterior circulation stroke: a population-based study. Lancet Neurol 2013;12:65–71.Web of SciencePubMedCrossrefGoogle Scholar

  • 18.

    National Association of Insurance Commissioners. Severityof injury. Medical Malpractice Closed Claims. 1980;2:304–6. http://www.naic.org/documents/prod_serv_special_med_lb.pdf. Accessed: 16 May 2017.

  • 19.

    Schiff GD, Puopolo AL, Huben-Kearney A, Yu W, Keohane C, McDonough P, et al. Primary care closed claims experience of Massachusetts malpractice insurers. J Am Med Assoc Intern Med 2013;173:2063–8.Google Scholar

  • 20.

    Singh H, Weingart SN. Diagnostic errors in ambulatory care: dimensions and preventive strategies. Adv Health Sci Educ Theory Pract 2009;14(Suppl 1):57–61.CrossrefPubMedGoogle Scholar

  • 21.

    Wallace E, Lowry J, Smith SM, Fahey T. The epidemiology of malpractice claims in primary care: a systematic review. BMJ Open 2013;3:e002929.CrossrefWeb of SciencePubMedGoogle Scholar

  • 22.

    Saber Tehrani AS, Lee H, Mathews SC, Shore A, Makary MA, Pronovost PJ, et al. 25-Year summary of US malpractice claims for diagnostic errors 1986–2010: an analysis from the National Practitioner Data Bank. BMJ Qual Saf 2013;22:672–80.CrossrefWeb of SciencePubMedGoogle Scholar

  • 23.

    Gupta A, Snyder A, Kachalia A, Flanders S, Saint S, Chopra V. Malpractice claims related to diagnostic errors in the hospital. BMJ Qual Saf 2018;27:53–60.Web of ScienceCrossrefGoogle Scholar

  • 24.

    Bhatt A, Safdar A, Chaudhari D, Clark D, Pollak A, Majid A, et al. Medicolegal considerations with intravenous tissue plasminogen activator in stroke: a systematic review. Stroke Res Treat 2013;2013:562564.PubMedGoogle Scholar

  • 25.

    Kachalia A, Gandhi TK, Puopolo AL, Yoon C, Thomas EJ, Griffey R, et al. Missed and delayed diagnoses in the emergency department: a study of closed malpractice claims from 4 liability insurers. Ann Emerg Med 2007;49:196–205.PubMedCrossrefWeb of ScienceGoogle Scholar

  • 26.

    Schiff GD, Hasan O, Kim S, Abrams R, Cosby K, Lambert BL, et al. Diagnostic error in medicine: analysis of 583 physician-reported errors. Arch Intern Med 2009;169:1881–7.PubMedCrossrefWeb of ScienceGoogle Scholar

  • 27.

    Gandhi TK, Kachalia A, Thomas EJ, Puopolo AL, Yoon C, Brennan TA, et al. Missed and delayed diagnoses in the ambulatory setting: a study of closed malpractice claims. Ann Intern Med 2006;145:488–96.CrossrefPubMedGoogle Scholar

  • 28.

    Tarnutzer AA, Lee SH, Robinson KA, Wang Z, Edlow JA, Newman-Toker DE. ED misdiagnosis of cerebrovascular events in the era of modern neuroimaging: a meta-analysis. Neurology 2017;88:1468–77.CrossrefPubMedWeb of ScienceGoogle Scholar

  • 29.

    Kerber KA, Brown DL, Lisabeth LD, Smith MA, Morgenstern LB. Stroke among patients with dizziness, vertigo, and imbalance in the emergency department: a population-based study. Stroke 2006;37:2484–7.PubMedCrossrefGoogle Scholar

  • 30.

    Drachman DA. A 69-year-old man with chronic dizziness. J Am Med Assoc 1998;280:2111–8.CrossrefGoogle Scholar

  • 31.

    Newman-Toker DE. Charted records of dizzy patients suggest emergency physicians emphasize symptom quality in diagnostic assessment. Ann Emerg Med 2007;50:204–5.Web of ScienceCrossrefPubMedGoogle Scholar

  • 32.

    Kerber KA, Newman-Toker DE. Misdiagnosing dizzy patients: common pitfalls in clinical practice. Neurol Clin 2015;33: 565–75.PubMedCrossrefWeb of ScienceGoogle Scholar

  • 33.

    Kerber KA, Morgenstern LB, Meurer WJ, McLaughlin T, HallPA, Forman J, et al. Nystagmus assessments documented by emergency physicians in acute dizziness presentations: a target for decision support? Acad Emerg Med 2011;18:619–26.CrossrefWeb of SciencePubMedGoogle Scholar

  • 34.

    Brown DL, Lisabeth LD, Garcia NM, Smith MA, Morgenstern LB. Emergency department evaluation of ischemic stroke and TIA: the BASIC Project. Neurology 2004;63:2250–4.CrossrefPubMedGoogle Scholar

  • 35.

    Graber ML. The incidence of diagnostic error in medicine. BMJ Qual Saf 2013;22(Suppl 2):ii21–7.CrossrefPubMedWeb of ScienceGoogle Scholar

  • 36.

    Localio AR, Lawthers AG, Brennan TA, Laird NM, Hebert LE, Peterson LM, et al. Relation between malpractice claims and adverse events due to negligence. Results of the Harvard Medical Practice Study III. N Engl J Med 1991;325:245–51.CrossrefPubMedGoogle Scholar

  • 37.

    Newman-Toker DE. A unified conceptual model for diagnostic errors: underdiagnosis, overdiagnosis, and misdiagnosis. Diagnosis (Berl) 2014;1:43–8.PubMedCrossrefGoogle Scholar

  • 38.

    Studdert DM, Mello MM, Gawande AA, Gandhi TK, Kachalia A, Yoon C, et al. Claims, errors, and compensation payments in medical malpractice litigation. N Engl J Med 2006;354:2024–33.PubMedCrossrefGoogle Scholar

  • 39.

    Andersson E, Bohlin L, Herlitz J, Sundler AJ, Fekete Z, Andersson Hagiwara M. Prehospital identification of patients with a final hospital diagnosis of stroke. Prehosp Disaster Med 2018;33:63–70.PubMedWeb of ScienceCrossrefGoogle Scholar

About the article

Corresponding author: Ava L. Liberman, MD, Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Stern Stroke Center, 3316 Rochambeau Avenue, 4th Floor, Bronx, NY 10467, USA, Phone: +(718) 920-6444, Fax: +(718) 654-0364


Received: 2019-04-09

Accepted: 2019-06-10

Published Online: 2019-07-11


Author contributions: All the authors have accepted responsibility for the entire content of this submitted manuscript and approved submission.

Research funding: Research reported in this publication was supported by the National Institute of Neurological Disorders and Stroke of the National Institutes of Health under Award Number K23NS107643. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Dr. Newman-Toker’s effort was supported by the Armstrong Institute Center for Diagnostic Excellence. No financial support for this study was provided by contract with any other agency, foundation, company, institute, or philanthropic foundation.

Employment or leadership: None declared.

Honorarium: None declared.

Competing interests: The funding organization(s) played no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the report for publication.

Conflicts of interest: ALL, JS, PG, and DS report no conflicts of interest. Dr. Newman-Toker has conducted government and foundation funded research related to diagnostic error, dizziness, and stroke. He has been loaned research equipment related to diagnosis of dizziness and stroke by two commercial companies (Natus/Otometrics and Interacoustics) and Johns Hopkins has licensed related diagnostic decision-support technology to Otometrics for which Dr. Newman-Toker has received a royalty payment; he occasionally serves as a paid consultant, reviewing medicolegal cases for both plaintiff and defense firms related to misdiagnosis of neurological conditions, including dizziness and stroke.


Citation Information: Diagnosis, 20190031, ISSN (Online) 2194-802X, ISSN (Print) 2194-8011, DOI: https://doi.org/10.1515/dx-2019-0031.

Export Citation

©2019 Walter de Gruyter GmbH, Berlin/Boston.Get Permission

Comments (0)

Please log in or register to comment.
Log in