Physician cognitive errors can lead to misdiagnosis

August 22, 2018

Doctors in high-stress environments may have the right information but don’t always act on it correctly, study finds.

Cognitive errors of information processing occurred at a higher rate than other medical errors, according to a recent study at an adult emergency department in an urban academic public hospital.

The study assessed patients who were admitted to the hospital on their second emergency visit within 72 hours of their first visit, over an eight-month period. A total of 52 cases of confirmed error were identified and classified during that time.

Faulty information processing occurred in 45% of cases, followed by faulty verification (31%), faulty information gathering (18%) and faulty knowledge (6%).

Principal investigator Benjamin Schnapp, MD, an assistant professor of emergency medicine at the University of Wisconsin in Madison, has a background in cognitive science. “I have always been fascinated by the intersection between medical diagnosis and the mind,” he told Contemporary OB/GYN. “With just a few scraps of information, experienced physicians can make amazing, lifesaving diagnoses in seconds. On the other hand, really great doctors can miss critical findings for reasons that we have yet to fully understand, but that can cause terrible consequences for patients.”

In certain ways, Dr. Schnapp is surprised by the study’s findings, which appear in the journal Diagnosis. “In the sometimes chaotic setting of an emergency room, supervised trainee physicians made up a large part of the workforce in our study,” he said. “In this setting, we thought we might find a large number of errors due to incomplete information from patients or inadequate medical knowledge. Instead, we found that the medical errors look a lot like the errors on the relatively more sedate inpatient floors; in other words, emergency doctors have the right information, but do not always make the correct decisions based on that information.”

To reduce the incidence of information processing errors, Dr. Schnapp recommends that physicians spend extra time with patients who continue to return for emergency visits. “Some of these patients are trying to give you the chance to pick up what was missed on their earlier visits,” he said. “Also, don’t be shy about asking a colleague for a fresh perspective.”

It is also important that physicians arrive at work rested and well fed. “Your brain is never going to function optimally if not taken care of properly,” Dr. Schnapp said.

Dr. Schnapp also encourages patients to return to the emergency room if their condition is not improving. “It is possible that a second chance to look at your case will allow doctors to put the pieces together in the right way,” he said.

Although much research has been devoted to medical errors caused by hospital-wide processes, there has been less focus on cognitive and diagnostic errors because these are much harder to pinpoint. “While some errors are obvious, some are much more subtle, and how do you say for sure when one has occurred?” Dr. Schnapp said. “We need to know which doctors and patients are at greatest risk for these errors, what conditions predispose clinicians to make them and the most effective methods for intervening to prevent errors.”

Dr. Schnapp said tools like checklists are helpful for some errors, but these are not necessarily a panacea because they fail to adequately address patient presentations that are not straightforward

Disclosures:

Dr. Schnapp reports no relevant financial disclosures.