Diagnostic errors in an accident and emergency department. Emerg Med J 18: 263-269

Accident and Emergency Department, Derriford Hospital, Plymouth PL6 8DH, UK.
Emergency Medicine Journal (Impact Factor: 1.84). 07/2001; 18(4):263-9. DOI: 10.1136/emj.18.4.263
Source: PubMed


To describe the diagnostic errors occurring in a busy district general hospital accident and emergency (A&E) department over four years.
All diagnostic errors discovered by or notified to one A&E consultant were noted on a computerised database.
953 diagnostic errors were noted in 934 patients. Altogether 79.7% were missed fractures. The most common reasons for error were misreading radiographs (77.8%) and failure to perform radiography (13.4%). The majority of errors were made by SHOs. Twenty two diagnostic errors resulted in complaints and legal actions and three patients who had a diagnostic error made, later died.
Good clinical skills are essential. Most abnormalities missed on radiograph were not difficult to diagnose. Junior doctors in A&E should receive specific training and be tested on their ability to interpret radiographs correctly before being allowed to work unsupervised.

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    • "However, overlooked injuries of the upper extremity have been shown to have a significant impact on limb survival, patient reconvalescence, and rehabilitation [6] [7]. "
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    ABSTRACT: The clavicle limits the upper thoracic cage and connects the body and upper extremities. The clavicle is easy to examine and is visible on standard emergency room radiographs. We hypothesized that clavicular fracture in polytrauma patients would indicate the presence of further injuries of the upper extremities, head, neck, and thorax. A population-based trauma registry was used. All patients were documented between 2002 and 2013. Inclusion criteria were age ≥16 y and injury severity score (ISS) ≥16. Patients were divided into two groups according to the presence or absence of a clavicular fracture (group C+ and group C-). Scoring was based on the abbreviated injury scale, ISS, and new injury severity score. Trauma mechanisms, demographics, and the posttraumatic clinical course were compared. In total, 4790 patients with clavicular fracture (C+) and 41,775 without (C-) were included; the mean ISS was 30 ± 11 (C+) versus 28 ± 12 (C-). Patients with clavicular fracture had a longer stay on the intensive care unit with 12 ± 14 versus 10 ± 13 d. Injuries to the thoracic wall, severe lung injuries as well as injuries to the cervical spine were significantly increased in C+ patients. Thoracic injuries as well as injuries of the shoulder girdle and/or arm showed an increased abbreviated injury scale in the C+ group. A clinically relevant coincidence of clavicular fractures with injuries of the chest and upper extremity was found. As clavicular fractures can be diagnosed easily, it might also help to reduce the incidence of missed injuries of the chest and upper extremity. Therefore, special attention should be paid on thoracic as well as upper extremity injures during the second and tertiary surveys in case of clavicular fractures. Copyright © 2015 Elsevier Inc. All rights reserved.
    Journal of Surgical Research 06/2015; DOI:10.1016/j.jss.2015.06.030 · 1.94 Impact Factor
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    • "Missed and or delayed diagnoses in the emergency department can have severe consequences and are a major patient safety concern [11,12]. Emergency departments often have inexperienced junior doctors seeing large numbers of patients of all ages every day; errors or missed diagnoses do occur [13,14]. The perception that ankle fractures have a low rate of sub-optimal outcome and negligible negative long term consequence are not founded in empirical data, with life impacts following ankle fractures potentially extending into a range of life domains beyond physical discomfort [15,16]. "
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    ABSTRACT: Background Radiographic examinations of the ankle are important in the clinical management of ankle injuries in hospital emergency departments. National (Australian) Emergency Access Targets (NEAT) stipulate that 90 percent of presentations should leave the emergency department within 4 hours. For a radiological report to have clinical usefulness and relevance to clinical teams treating patients with ankle injuries in emergency departments, the report would need to be prepared and available to the clinical team within the NEAT 4 hour timeframe; before the patient has left the emergency department. However, little is known about the demand profile of ankle injuries requiring radiographic examination or time until radiological reports are available for this clinical group in Australian public hospital emergency settings. Methods This study utilised a prospective cohort of consecutive cases of ankle examinations from patients (n = 437) with suspected traumatic ankle injuries presenting to the emergency department of a tertiary hospital facility. Time stamps from the hospital Picture Archiving and Communication System were used to record the timing of three processing milestones for each patient’s radiographic examination; the time of image acquisition, time of a provisional radiological report being made available for viewing by referring clinical teams, and time of final verification of radiological report. Results Radiological reports and all three time stamps were available for 431 (98.6%) cases and were included in analysis. The total time between image acquisition and final radiological report verification exceeded 4 hours for 404 (92.5%) cases. The peak demand for radiographic examination of ankles was on weekend days, and in the afternoon and evening. The majority of examinations were provisionally reported and verified during weekday daytime shift hours. Conclusions Provisional or final radiological reports were frequently not available within 4 hours of image acquisition among this sample. Effective and cost-efficient strategies to improve the support provided to referring clinical teams from medical imaging departments may enhance emergency care interventions for people presenting to emergency departments with ankle injuries; particularly those with imaging findings that may be challenging for junior clinical staff to interpret without a definitive radiological report.
    Journal of Foot and Ankle Research 05/2014; 7(1):25. DOI:10.1186/1757-1146-7-25 · 1.46 Impact Factor
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    • "Buduhan et al. reported that 33.3% of upper extremity injuries were overlooked [4], while Kalemoglu et al. reported a rate of 38.2% [5]. In terms of wrist, hand and arm injuries, Guly reported rates of 17.2%, 21.7% and 15.1% of missed injuries, respectively [6]. Other authors reported that 4–8% (wrist/hand) and 11–12% (arm) of injuries of the upper extremities were missed. "
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    ABSTRACT: Thoracic and extremity injuries are common in polytraumatized patients. The clavicle limits the upper thoracic cage and connects the body and upper extremities. It is easy to examine and is visible on standard emergency room radiographs. We hypothesize that clavicular fracture in polytrauma patients indicates the presence of further injuries of the upper extremities, head, neck and thorax.Material & methods: Retrospective study including patients admitted between 2008 and 2012 to a level-I trauma center. Inclusion criteria: ISS > 16, two or more injured body regions, clavicular fracture. Control group: patients admitted in 2011, ISS > 16, two or more injured body regions, no clavicular fracture. Patient information was obtained from the patients' charts; evaluation of radiographic findings was performed; scoring was based on the Abbreviated Injury Scale (AIS) and Injury Severity Score (ISS) AIS/ISS; data were analyzed using Pearson's correlation and the Mann--Whitney U-test in SPSS (version 11.5.1); graphs were drawn using EXCEL(R). Thirty-four patients with clavicular fracture (C+) and 40 without (C-) were included; the mean ISS was 25 (range 16--57), m = 70%, f = 30%; age 43.3 years (range 9--88); clavicular fractures were positively correlated with severe thoracic (p = 0.011, OR 4.5: KI 1.3--15.3), external (p < 0.001, OR 9.2: KI 2.7--30.9) and upper extremity injuries (p < 0.001, OR 33.2: KI 6.9--16.04 resp. p = 0.004, OR 12.5: KI 1.5--102.9). C + showed a lower head/neck AIS (p = 0.033), higher thorax AIS (p = 0.04), arm/shoulder AIS (p = 0.001) and external AIS (0.003) than C-. Mean hospital stay and ICU treatment time were longer in the C + group (p = 0.001 and p = 0.025 respectively). A clavicular fracture can be diagnosed easily and may be used as a pointer for further thoracic and upper extremity injuries in polytrauma patients that might have been otherwise missed. Special attention should be paid on second and tertiary survey.
    Patient Safety in Surgery 07/2013; 7(1):23. DOI:10.1186/1754-9493-7-23
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