Connecting With Patients—The Missing Links

Missed or delayed diagnoses are a common but understudied area in patient safety research. To better understand the types, causes, and prevention of such errors, we surveyed clinicians to solicit perceived cases of missed and delayed diagnoses. A 6-item written survey was administered at 20 grand rounds presentations across the United States and by mail at 2 collaborating institutions. Respondents were asked to report 3 cases of diagnostic errors and to describe their perceived causes, seriousness, and frequency. A total of 669 cases were reported by 310 clinicians from 22 institutions. After cases without diagnostic errors or lacking sufficient details were excluded, 583 remained. Of these, 162 errors (28%) were rated as major, 241 (41%) as moderate, and 180 (31%) as minor or insignificant. The most common missed or delayed diagnoses were pulmonary embolism (26 cases [4.5% of total]), drug reactions or overdose (26 cases [4.5%]), lung cancer (23 cases [3.9%]), colorectal cancer (19 cases [3.3%]), acute coronary syndrome (18 cases [3.1%]), breast cancer (18 cases [3.1%]), and stroke (15 cases [2.6%]). Errors occurred most frequently in the testing phase (failure to order, report, and follow-up laboratory results) (44%), followed by clinician assessment errors (failure to consider and overweighing competing diagnosis) (32%), history taking (10%), physical examination (10%), and referral or consultation errors and delays (3%). Physicians readily recalled multiple cases of diagnostic errors and were willing to share their experiences. Using a new taxonomy tool and aggregating cases by diagnosis and error type revealed patterns of diagnostic failures that suggested areas for improvement. Systematic solicitation and analysis of such errors can identify potential preventive strategies.

Key Points Question Which electronic health record (EHR) design and use factors are associated with clinician stress and burnout? Findings In this survey study of 282 clinicians, clinician stress and burnout were associated with 7 EHR design and use factors. These 7 plus 2 other design and use factors collectively accounted for a modest amount of the variance in stress (12.5%) and burnout (6.8%); models incorporating other work conditions (such as chaotic work atmosphere and workload control) accounted for considerably more of the variance in stress (58.1%) and burnout (36.2%). Meaning While EHR design and use factors may appropriately be targeted by health systems and EHR designers to address stress and burnout, other non-EHR issues, especially clinician work conditions, appear to play a substantial role in adverse clinician outcomes.