New research has found that diagnostic errors were common among patients with spinal epidural abscesses. The research, published in an article in the
American Journal of Medicine, was based on Department of Veterans Affairs health records of patients with the condition, which can lead to spinal compression and severe health problems if not treated. Reviewing records of 119 patients with spinal epidural abscesses, researchers found that 56 percent had experienced diagnostic error. Red flags that were frequently missed in the error cases included unexplained fever, neurological deficits with progressive or disabling symptoms, and infection. The study’s authors, funded in part by AHRQ, concluded that diagnostic errors resulted from inadequate patient histories, physical exams and test ordering. Access the
abstract.
Am J Med. 2017 Mar 30. pii: S0002-9343(17)30323-6. doi: 10.1016/j.amjmed.2017.03.009. [Epub ahead of print]
Errors in Diagnosis of Spinal Epidural Abscesses in the Era of Electronic Health Records.
Abstract
PURPOSE:
To identify missed opportunities in diagnosis of spinal epidural abscesses to outline areas for process improvement. METHODS:
Using a large national clinical data repository, we identified all patients with a new diagnosis of spinal epidural abscess in the Department of Veterans Affairs (VA) during 2013. Two physicians independently conducted retrospective chart reviews on 250 randomly selected patients and evaluated their records for red flags (e.g., unexplained weight loss, neurological deficits, and fever) 90 days prior to diagnosis. Diagnostic errors were defined as missed opportunities to evaluate red flags in a timely or appropriate manner. Reviewers gathered information about process breakdowns related to patient factors, the patient-provider encounter, test performance and interpretation, test follow-up and tracking, and the referral process. Reviewers also determined harm and time lag between red flags and definitive diagnoses. RESULTS:
Of 250 patients, 119 had a new diagnosis of spinal epidural abscess, of which 66 (55.5%) experienced diagnostic error. Median time to diagnosis in error cases was 12 days compared to 4 days without error (P<0.01). Red flags that were frequently not evaluated in error cases included unexplained fever (n=57;86.4%), focal neurological deficits with progressive or disabling symptoms (n=54;81.8%) and active infection (n=54;81.8%). Most errors involved breakdowns during the patient-provider encounter (n=60;90.1%), including failures in information gathering/integration, and were associated with temporary harm (n=43;65.2%). CONCLUSIONS:
Despite wide availability of clinical data, errors in diagnosis of spinal epidural abscesses are common and involve inadequate history, physical exam and test ordering. Solutions should include renewed attention to basic clinical skills. Copyright © 2017. Published by Elsevier Inc.
KEYWORDS:
back pain; diagnostic delays; diagnostic errors; red flags; spinal epidural abscess
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