AHRQ’s Web M&M Explores Diagnosis in Primary Care

The current issue of AHRQ Web M&M features a Spotlight Case describing a 54-year-old man with no significant medical history who went to a new primary care physician complaining of 2 years of progressive numbness in his hands and feet, pain and weakness. The patient was diagnosed with peripheral neuropathy, a loss of sensation that typically begins in the hands and feet, and referred to a neurologist. With symptoms worsening, the patient saw two different providers at the same clinic over the next 10 weeks. Neither ordered additional tests, relying instead on the original diagnosis. When he finally went to the neurology clinic, an urgent magnetic resonance imaging of the spinal cord revealed critical cervical cord compressions so tight he was at risk for permanent paralysis. A root cause analysis of the case revealed that none of the doctors who had seen the patent had checked his reflexes or overall muscle tone. The Perspective on Safety section of the issue features an interview with Tejak K. Gandhi, M.D., M.P.H., President of the National Patient Safety Foundation and Associate Professor of Medicine at Harvard Medical School, about the foundation’s evolving role in enhancing health care. Also featured is a conversation with Leah Binder, M.A., M.G.A., President and CEO of the Leapfrog Group, about efforts to address key health policy issues and the development of the Hospital Safety Score.