Prevalence and Causes of Diagnostic Errors in Hospitalized Patients Under Investigation for COVID-19

Prevalence and Causes of Diagnostic Errors in Hospitalized Patients Under Investigation for COVID‑19 Andrew D. Auerbach, MD, MPH1 , Gopi J. Astik, MD2, Kevin J. O’Leary, MD2, Peter N. Barish, MD1, Molly A. Kantor, MD1, Katie R. Raffel, MD3, Sumant R. Ranji, MD4, Stephanie K. Mueller5, Sharran N. Burney, MSN, RN, NP6, Janice Galinsky, MSN, RN, NP6, Esteban F. Gershanik, MD5, Abhishek Goyal, MD5, Pooja R. Chitneni, MD5, Sarah Rastegar, MD6, Armond M. Esmaili, MD1, Cynthia Fenton, MD1, Anunta Virapongse, MD3, Li‑Kheng Ngov, MD3, Marisha Burden, MD3, Angela Keniston, PhD3, Hemali Patel, MD3, Ashwin B. Gupta, MD7,8, Jeff Rohde, MD7, Ruby Marr, MD7, S. Ryan Greysen, MD, MHS9, Michele Fang, MD9, Pranav Shah, MD9, Frances Mao, MD9, Farah Kaiksow, MD10, David Sterken, MD10, Justin J. Choi, MD11, Jigar Contractor, MD11, Abhishek Karwa, MD4, David Chia, MD4, Tiffany Lee, BA1, Colin C. Hubbard, PhD1, Judith Maselli, MPH1, Anuj K. Dalal, MD5, and Jeffrey L. Schnipper, MD, MPH5 1 Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA; 2Division of Hospital Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; 3Division of Hospital Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; 4Division of Hospital Medicine, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA; 5Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, and Harvard Medical School, Boston, MA, USA; 6Brigham and Women’s Faulkner Hospital, Boston, MA, USA; 7Division of Hospital Medicine, University of Michigan Medical School, Ann Arbor, MI, USA; 8Division of Hospital Medicine, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA; 9Section of Hospital Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; 10 Division of Hospital Medicine, University of Wisconsin School of Medicine and Public Health, WI, Madison, USA; 11Department of Medicine, Weill Cornell Medical College, New York, NY, USA ABSTRACT BACKGROUND: The COVID-19 pandemic required clinicians to care for a disease with evolving characteristics while also adhering to care changes (e.g., physical distancing practices) that might lead to diagnostic errors (DEs). OBJECTIVE: To determine the frequency of DEs and their causes among patients hospitalized under investigation (PUI) for COVID-19. DESIGN: Retrospective cohort. SETTING: Eight medical centers affiliated with the Hospital Medicine ReEngineering Network (HOMERuN). TARGET POPULATION: Adults hospitalized under investigation (PUI) for COVID-19 infection between February and July 2020. MEASUREMENTS: We randomly selected up to 8 cases per site per month for review, with each case reviewed by two clinicians to determine whether a DE (defined as a missed or delayed diagnosis) occurred, and whether any diagnostic process faults took place. We used bivariable statistics to compare patients with and without DE and multivariable models to determine which process faults or patient factors were associated with DEs. RESULTS: Two hundred and fifty-seven patient charts underwent review, of which 36 (14%) had a diagnostic error. Patients with and without DE were statistically similar in terms of socioeconomic factors, comorbidities, risk factors for COVID-19, and COVID-19 test turnaround time and eventual positivity. Most common diagnostic Received December 4, 2022 Accepted March 13, 2023 process faults contributing to DE were problems with clinical assessment, testing choices, history taking, and physical examination (all p < 0.01). Diagnostic process faults associated with policies and procedures related to COVID-19 were not associated with DE risk. Fourteen patients (35.9% of patients with errors and 5.4% overall) suffered harm or death due to diagnostic error. LIMITATIONS: Results are limited by available documentation and do not capture communication between providers and patients. CONCLUSION: Among PUI patients, DEs were common and not associated with pandemic-related care changes, suggesting the importance of more general diagnostic process gaps in error propagation. J Gen Intern Med DOI: 10.1007/s11606-023-08176-6 © The Author(s) 2023 INTRODUCTION Diagnostic errors (DEs) are “the failure to (a) establish an accurate and timely explanation of the patient’s health problem(s) or (b) communicate that explanation to the patient.”1 Many factors contribute to diagnostic errors, but key among them are complex and fragmented care systems, the limited time available to providers trying to ascertain a firm diagnosis, and the work systems and cultures that impede improvements in diagnostic performance.2–8 In the hospital setting, work burden, patient acuity, and technology Vol.:(0123456789) Auerbach et al: Prevalence and Causes of Diagnostic Errors in Patients (such as electronic health records [EHRs] and multiple “alerting” systems9) all contribute. In the early stages of the COVID-19 pandemic, these preexisting problems were exacerbated in ways that have yet to be fully elucidated.10 Shortages of personal protective equipment (PPE) and concerns about workforce preservation led hospitals to replace physical visits with videoconferencing or telephone-based encounters.11–17 Hospital visitor restrictions impaired or delayed collaborative discussions with patients’ family members, potentially limiting clinicians’ ability to obtain thorough clinical histories. Changes in coverage models (e.g., internal medicine providers providing critical care services18) changed the clinical expertise of physicians caring for COVID-19 patients. Data from our network suggested that half of hospitalist leaders surveyed related a missed or delayed non-COVID-19 diagnosis among patients under investigation (PUI) for COVID-19 infection. A similar proportion also reported missing COVID-19 as a diagnosis in patients admitted for other medical reasons,13 consistent with conceptual models published early in the pandemic.10 This study, undertaken at the height of the first wave of the COVID-19 pandemic, sought to gain an understanding of the prevalence of diagnostic errors among PUIs or with confirmed COVID-19 infection and to gather insights into whether changes in health care policies and procedures during the pandemic might have contributed to these errors. METHODS Study Design This was a retrospective multicenter cohort study of randomly selected patients admitted under investigation for COVID-19 investigation. Sites and Subjects This study was undertaken as a collaboration among eight academic centers participating in the Hospital Medicine ReEngineering N etwork19 who were already conducting diagnostic error case reviews as part of a larger research study.20 Sites in this study represented a range of settings, including locations such as New York City which were affected more significantly by the pandemic (...truncated)