When we try to dissect through the various confounding factors that contribute to delays and errors in diagnosis, it is important to understand that only by delving deeply can one realize opportunities for improvements. In the case of human errors, or what I prefer to call human mistakes, there are often multiple contributing factors and thus many opportunities for improvements1. When investigations fail to delve deeply to identify contributing factors, then processes do not improve, professionals and institutions do not learn from past mistakes and patients may continue to suffer.
Case Study:
A 35-year-old woman was evaluated for a firm mass to the left of midline in her neck. The 2cm mass had been present for about two months and had slowly enlarged. The patient complained of minimal pain with swallowing. She had been reluctant to seek medical care, but her sister insisted she seek an evaluation and brought her to the clinic. At her sister’s urging, the clinic squeezed her in as the last patient of the day. The physician scheduled to see her was double-booked for the last three appointment slots. He also was rushing to make rounds on four patients at the local hospital before hosting a discussion that evening at a journal club.
The patient’s past history revealed that she had previously had a thyroglossal duct cyst (congenital cyst in the neck related to development of the thyroid gland) removed at age 14. She was generally well otherwise, although she had recently lost about seven pounds and complained of fatigue and anxiety, which she attributed to recent problems with her job and her boyfriend. The patient was well known to clinic staff. She was considered by the nurses to be a hypochondriac with a physician phobia and a history of non-compliance with recommendations.
Apart from a description of the mass, nothing else was noted in her medical record regarding other aspects of a physical examination.
Lab studies were ordered, including a blood count, blood chemistries and thyroid studies, and a thyroid scan. Two weeks later, the physician called the patient to discuss the thyroid studies and scan, both normal. A presumptive diagnosis was made of recurrent thyroglossal duct cyst. Because the patient was reluctant to undergo surgery again, she was advised to have a return evaluation in three months or sooner if the mass became enlarged or acutely tender. The patient was reassured that her fatigue and anxiety most likely were related to her work situation and life stresses.
Unfortunately, the other lab studies had never been reviewed by the physician. The studies later were found to reveal moderate anemia and an elevated white blood cell count with abnormal cell types.
Four months later, the patient presented to an emergency department with shortness of breath and a recent history of night sweats. She was found to have a large chest mass, massive swollen glands in her neck and armpits, an enlarged liver and spleen, and laboratory studies consistent with acute lymphoblastic leukemia.
This patient was the victim of a patient safety incident, delayed/missed diagnosis resulting in delayed treatment. Fortunately, the patient underwent aggressive chemotherapy and entered a long-lasting remission.
An investigation into this incident identified the physician’s failure as the root cause for this delayed diagnosis. The physician was taken to task for not having performed a complete physical examination and for not following up on the laboratory results ordered during the first evaluation. Yet if blame is the sole result of an investigation, then the investigation has been incomplete. The physician was responsible for the care of the patient and appropriately should be held accountable, but only by delving a bit deeper beneath the surface can opportunities for learning and improvements be identified.
A more thorough investigation revealed the following:
1. The physician was overbooked, rushed and task saturated with numerous end-of-day obligations distracting his attention. He utilized attribution bias in his rush to diagnosis, a common mistake that good doctors frequently make.
2. According to the physician interview, a complete physical exam had been done, but documentation in the medical record was grossly incomplete.
3. The clinic had no tracking mechanism to assure that tests ordered were obtained, that results were received and reported to/acknowledged by the physician.
4. The clinic had no tracking mechanism to ensure patient follow-up appointments.
5. Although the patient was known to have physician phobia, the clinic staff did not flag her for special attention and did not call the patient to assure follow-up.
A superficial investigation assigned blame but failed to identify numerous system and process opportunities for learning and improvement by individuals and institutions. Sloppy work of little value!
Reference:
1. Cohen D. Unraveling Diagnostic Error – The Impact of “Hidden” Human Factors, PSQH Nov/Dec 2016:28-32.