Abstract
Purpose
With this study, we
set out to identify missed opportunities in diagnosis of spinal
epidural abscesses to outline areas for process improvement.
Methods
Using a large
national clinical data repository, we identified all patients with a
new diagnosis of spinal epidural abscess in the Department of
Veterans Affairs (VA) during 2013. Two physicians independently
conducted retrospective chart reviews on 250 randomly selected
patients and evaluated their records for red flags (eg, unexplained
weight loss, neurological deficits, and fever) 90 days prior to
diagnosis. Diagnostic errors were defined as missed opportunities to
evaluate red flags in a timely or appropriate manner. Reviewers
gathered information about process breakdowns related to patient
factors, the patient–provider encounter, test performance and
interpretation, test follow-up and tracking, and the referral
process. Reviewers also determined harm and time lag between red
flags and definitive diagnoses.
Results
Of 250 patients, 119
had a new diagnosis of spinal epidural abscess, 66 (55.5%) of which
experienced diagnostic error. Median time to diagnosis in error cases
was 12 days, compared with 4 days in cases without error (P less than
.01). Red flags that were frequently not evaluated in error cases
included unexplained fever (n = 57; 86.4%), focal neurological
deficits with progressive or disabling symptoms (n = 54; 81.8%), and
active infection (n = 54; 81.8%). Most errors involved breakdowns
during the patient–provider encounter (n = 60; 90.1%), including
failures in information gathering/integration, and were associated
with temporary harm (n = 43; 65.2%).
Conclusion
Despite wide
availability of clinical data, errors in diagnosis of spinal epidural
abscesses are common and involve inadequate history, physical
examination, and test ordering. Solutions should include renewed
attention to basic clinical skills.
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