Experts interviewed: Beijing Emergency CenterSenior first aid expert Jia Dacheng
Global Times Health Client reporter Zhang Jian
Recently, a new research report released by the Agency for Healthcare Research and Quality of the U.S. Department of Health and Human Services pointed out that 7.4 million emergency room misdiagnoses occur in the United States every year.
The report reviewed 279 studies published between January 2000 and September 2021 reporting on harms associated with diagnostic errors or misdiagnosis in emergency departments in the United States or other developed countries. Researchers estimate that of the 130 million emergency department visits in the United States each year, 7.4 million (5.7%) are misdiagnosed, 2.6 million (2%) suffer adverse events as a result, and approximately 370,000 (0.3%) suffer serious harm as a result of misdiagnosis. This means that approximately 1 in 18 emergency department patients are misdiagnosed, 1 in 50 emergency department patients suffers an adverse event, and 1 in 350 emergency department patients is permanently disabled or dies. These misdiagnosis rates are comparable to rates in primary care and hospital inpatient care.
The report shows that these 15 diseases account for 68% of all serious misdiagnosis-related harms: (1) Stroke ; (2) Myocardial infarction; (3) Aortic aneurysm / Aortic dissection ; (4) Spinal cord compression/injury; (5) Venous thromboembolism; (6) meningitis and encephalitis; (7) sepsis, tied for sixth; (8) lung cancer; (9) traumatic brain injury and traumatic intracranial hemorrhage; (10) arterial thromboembolism; (11) spinal cord and intracranial abscess; (12) cardiac arrhythmia; Among them, the top five diseases accounted for 39% of all serious misdiagnosis-related harms.
The misdiagnosis rate of different diseases varies greatly. For example, the lowest is myocardial infarction (1.5%), which is the only disease with a missed diagnosis rate close to zero, which is far lower than the average misdiagnosis rate of all diseases (5.7%); the highest is spinal cord abscess, 56%, and the misdiagnosis rate of the other top 13 diseases is 10% to 36%. Among them, misdiagnosis of stroke is the most serious disease causing harm, and about 17% of patients are missed.
For certain diseases, non-specific or atypical symptoms increase the likelihood of misdiagnosis. For example, symptoms of dizziness or vertigo are 14 times more likely to be misdiagnosed than stroke impairment. About 40% of patients with atypical stroke symptoms who only have dizziness and vertigo are initially missed in the emergency room.
There are also great differences in the misdiagnosis rates of different ages. Younger age increases the risk of missed diagnosis of stroke by 6.7 times; the older the age, the higher the risk of missed diagnosis of appendicitis. In addition, women and people of color have a 20% to 30% increased risk of being misdiagnosed. In addition, the emergency misdiagnosis rate in specific hospitals varies greatly, and the misdiagnosis rate varies even 100 times between different hospitals. Typically in teaching hospitals, emergency department misdiagnosis rates are relatively low. Jia Dacheng, a senior emergency expert at the Beijing Emergency Center, told the "Global Times Health Client" reporter that this is because the diagnosis and treatment style of teaching hospitals is more rigorous, which also shows that there is room for improvement in the emergency misdiagnosis rates of various hospitals. According to Jia Dacheng, misdiagnosis and missed diagnosis are prone to occur in emergency departments for two reasons: First, emergency rescue time is tight, and doctors are not allowed to spend several days to figure out the cause of the disease like chronic diseases. Doctors must deal with the condition quickly; second, the personal experience of emergency doctors is related to the lack of relevant auxiliary examinations. For example, some biochemical tests may take several hours to produce results to help doctors diagnose the condition.
However, in response to the above report, ten emergency physician groups, including the American College of Emergency Physicians and the American Board of Emergency Medicine, issued a rebuttal letter, saying that the report was "incomplete" and "misleading." They believe that there is indeed room for improvement in emergency room diagnostic accuracy, but “it is incorrect to characterize emergency room misdiagnosis and missed diagnosis as errors.” This misunderstands the goals of emergency medicine, which prioritizes stabilization of critically ill patients and identification of life-threatening situations. The role of the emergency physician is to ensure that the patient begins on the appropriate path to care leading to final diagnosis and treatment.
“The report reminds us that it is important to reduce the incidence of misdiagnosis in emergency departments."Jia Dacheng said that emergency doctors must have two characteristics: first, they must have a strong sense of responsibility; second, they must have a high technical level. Both are indispensable. Emergency doctors face life and must have a strong sense of responsibility. They must have rich professional knowledge and mature diagnosis and treatment technology to avoid and reduce missed diagnosis and misdiagnosis.
Jia Dacheng reminded that to reduce Four things must be done to avoid misdiagnosis: During the consultation process, the doctor should first focus on asking the patient's medical history, and perform physical examinations such as visual inspection, palpation, percussion, and listening. The doctor's consultation level is also very important. Usually, the patient will not exaggerate or minimize the condition, but the inaccurate description of the condition may mislead the doctor. The clinician has a high level of consultation and can ask the patient’s medical history and pathogenesis clearly. At the same time, doctors should ask patients for targeted examinations. Examination is necessary, but emergency doctors cannot rely too much on instruments. Jia Dacheng once encountered a patient who reported chest pain and was also pale. The electrocardiogram showed a typical " acute inferior wall myocardial infarction " pattern. However, Jia Dacheng suspected that the patient did not have a myocardial infarction, so he tried to make the patient inhale and cough, but the pain became more obvious. When he slapped the patient's chest on both sides, the sounds on both sides were very different. Jia Dacheng found that there was a "dong dong dong" sound on one side of the patient. Therefore, the patient was advised to take a chest X-ray. Finally, the patient was diagnosed with pneumothorax (gas entered the pleural cavity, causing pneumothorax). “This patient could easily have been misdiagnosed based only on the electrocardiogram. "Jia Dacheng said that some diseases have no specificity and typical symptoms. If a doctor has no experience or cannot think of possible diseases, he cannot conduct further targeted examinations and is easily misdiagnosed.
Emergency doctors must adhere to the principle that they must do the examinations that should be done and not do the ones that should not be done. Patients and their families cannot be bothered. Walk with your nose . Jia Dacheng reminded that if some patients have severe abdominal pain and only ask for pain relief, if the doctor uses analgesics before making a clear diagnosis, it will cover up the real condition and even endanger their lives.
Emergency doctors should also pay attention to popular science. Popular science can make patients and their families trust doctors, better cooperate with examinations and treatments, reduce medical disputes, and also reduce missed diagnosis and misdiagnosis. Many patients do not listen to doctors’ recommendations for examinations, or mislead doctors by inaccurately stating their condition because of their insufficient health literacy.
Patients and family members can also help reduce misdiagnosis and missed diagnosis. The first is to cooperate with the emergency doctor for examination. Because time is tight, many doctors use the elimination method in emergency situations, such as asking patients to do an electrocardiogram to rule out myocardial infarction. In this regard, patients and family members must actively cooperate and cannot refuse to cooperate just because they think the problem is not serious. The second is to state the medical history and condition in detail. ▲
