Ebola in Dallas – a classic diagnostic error

15

Category : Medical Rants

All attempts at measuring quality in medicine depend on correct diagnosis. Diagnostic accuracy represents the lynchpin of high quality care.

As everyone knows, the first US Ebola diagnosed patient visited an emergency department at the onset of his illness, but did not get diagnosed properly or admitted to the hospital.

Few doctors would have made the proper diagnosis in this situation. We must accept that diagnostic errors are common. This situation was particularly difficult because very few physicians in the US had previously seen a patient with Ebola.

In order to make a diagnosis, you must consider that diagnosis. The patient likely presented with classic viral symptoms.

Talking heads now opine that the doctors should have taken a better travel history, and that the travel history would have given the clue. That is a very easy but naive belief.

We rarely make diagnoses for which we do not have a high index of suspicion.

This example of diagnostic error should alert everyone to the importance of accurate diagnosis. We all know the potential problem that this patient may have created – a mini-epidemic from one patient.

Accurate diagnosis is the precursor to high quality care. We cannot measure physician quality without considering diagnosis. Unfortunately diagnostic accuracy is very difficult to measure. And there lies the conundrum of high quality care.

Comments (15)

Dr. C:
Sorry, I love you, but on this one you couldn’t be more wrong.

The whole country was on high alert about Ebola.

The CDC had sent warnings around about Ebola.

Yes, the patient had garden variety flu symptoms, BUT THE DOCTORS DIDN’T EVEN ASK ABOUT TRAVEL TO AN ENDEMIC AREA FOR EBOLA (which the nurse elicited and the patient was more than willing to give).

There was zero excuse not to consider it, or at least get an ID evaluation in the ER. It was done because they did not take a history- that is the source of the diagnostic error in this case. They didn’t even have to make the diagnosis, all they to do was suspect it. Let’s not get too taken in by airy-fairy notions of “high-quality care”. Do the essentials of a good medical evaluation. That’s not naive, that’s good medicine.

Of course hundreds of people come into the ER every day with the same symptoms but the whole point is hundreds don’t come in every day having just returned form Liberia -and in fact a few more questions would have prompted the answers that he actually had contact with Ebola.

And we can throw in the electronic medical record too. Overreliance on what turned out to be a bad technology- that didn’t let nursing information talk to doctor information. Would not have happened in the day of paper record.

And for this – over 100 people have been exposed and a small area of Dallas is on lock down. All because educators didn’t do their own history. Billions of dollars of prevention and technology can be negated by something you would formerly have failed a sophomore medical student for

When did that become acceptable in medicine?

Sorry, in my rant
“educators” should read “the doctors”
Computer miscorrection. (unintended irony)

I did not mean to imply that the error is acceptable, rather that is understandable. Diagnostic errors are common, partly because diagnostic accuracy is not a quality measure. While some medical educators still stress diagnosis, my impression is that many do not.

Diagnostic errors should attract much more attention. Cory is partly correct, the doctors should have asked, but I would bet much money that many patients with flu-like symptoms around the US have not been asked a travel history.

And more have been asked this week than ever before.

I have been told several times by adminstrators that it’s more efficient for the support staff to take the history, then I can focus more on the treatment plan, give my blessing, and ultimately see more patients.

Because let’s not forget, seeing more patients (and billing for seeing more patients) is always the right answer. And taking a history is a time waster that others “practicing to the top of their license” can do.

Great point. I do not trust ANYONE else to take the history. Taking a history is very complex and nuanced. This is exactly why computers cannot replace us in diagnosis. History taking is the most important skill in diagnosis. If the physicians involved had thought to get a travel history, perhaps …

It’s worse than you think, and in a slightly different direction.

According to a piece in today’s HealthLeaders, the intake/triage RN did note the patient’s recent travel in Africa (he had been asked, and answered in the affirmative), but EHR workflow “localized optimization” prevented the MDs from seeing that note.

In a statement, Texas Presby said, “”The documentation of the travel history was located in the nursing workflow portion of the EHR, and was designed to provide a high reliability nursing process to allow for the administration of influenza vaccine under a physician-delegated standing order.
As designed, the travel history would not automatically appear in the physician’s standard workflow.”

You can’t MAKE the right diagnosis with all the pertinent information. So I don’t fault the clinical team on this one. That fault lies squarely with the eejits who designed the workflow on the hospital’s EHR.

*without the right information (sigh)

Spot on!

No, sorry Casey, that’s not spot on.
OK, so the EMR is bad. that’s a different problem – it contributed to this but if the autopilot in the plane breaks I’m still supposed to now how to fly.

What possible excuse can you give for the ER physicians not to have asked whether he had been to West Africa?

They are the ones who are supposed to take the history. IT’s part of their job.
Sure lots of people don’t ask travel history for cold sand stuff, but the CDC just announced a high-profile surveillance for Ebola. Plus the patient resides in a section of Dallas with West African patients.
If you put all the blame on the EMR, and Lord knows I hate EMR and have made no secret of it, you are letting the physicians off the hook and encouraging them not to take histories.

Look- those administrators who tell you to let someone else take the history are telling you to practice bad medicine. Pure and simple. IF you know what you are doing you will take a better history anyway. You can decide what you want to do about following their edicts, everyone has to do what they have to, but make no mistake what they are telling you to do is wrong and indefensible. See what happens if you get sued for missing a key point in a history- which might happen here. No one is going to buy the administrator told me not to take the history.
And look what happened here –

Military people will tell you soldiers are losing the ability to use a map and compass because they are so dependent on GPS- so a smart GPA missile becomes a dumb one.

IF history taking is not important – then just stop teaching it in med school. See how far the profession would get.

I’m going to go out on a limb but I bet that ER MD’s note for that visit had a lot of ” agree with the past medical history, meds, allergies, social history, and family history as charted by the RN ” type verbage. Let’s face it there is too much short cutting going on in medicine today. The mentality is there is really not much to gain from the history. Lab and Rad ’em up, that’s the name of the game. I gotta side with Cory on this one. The MD just failed to get a history, I bet he felt it was a waste of time.

Hopefully this case will bring good diagnosis and history back.

I am amazed by HPI of one- two line these days even by experienced doctors (patient presented to ER with shortness of breath and is now admitted with pneumonia). How many times are we making incorrect diagnosis and choosing incorrect treatment strategies everyday…. More than 1 + 100 Ebola contacts. Who will speak out for them? I bet their paperwork ( oh sorry…EMR) looks pristine.

[…] ability to read words on a website doesn't always correlate with the ability to perform an accurate medical diagnosis. In fact, in these types of situations, the average person attempting to diagnose his condition can […]

… Late Friday – 24 hours after releasing the details in “in the interest of transparency” – the hospital reversed part of its account. Unlike before, they said Duncan’s travel history was visible to all in the hospital’s electronic health record (EHR) system.

“There was no flaw in the EHR in the way the physician and nursing portions interacted related to this event,” the hospital said in a written statement.

But as of Saturday afternoon, no other explanation for the oversight has been given. Emails to the hospital with specific questions from Yahoo News have not been returned for days.

http://twitchy.com/2014/10/05/not-a-glitch-hospital-in-dallas-backtracks-and-now-admits-it-knew-ebola-patients-travel-history-before-releasing-him/

This was not a diagnostic error. It was pure negligence. Another ER physician depends on a professional handmaiden to take the history, fill in the boxes for maximal reimbursement and come in to sign the demand draft.
The physician failed to take a history, if briefed about CDC concerns by the hospital the error is greater.
To prescribe an “antibiotic” for av viral infection compounds the error.
Forget politically correct statements, is it not time we started taking histories again?

Cory is absolutely correct. An MD not taking a travel history *personally* is NOT practicing good medicine, period. ou do NOT have the luxury of blaming it on an RN or an EMR. In the current context, it’s inexcusable : the need for a travel history has been pushed for months now as part of the Ebola strategy. A good MD ALWAYS takes a travel history, not just in the context of Ebola : it’s why malaria gets missed.

Post a comment