Advertisement

Inadequacies of Physical Examination as a Cause of Medical Errors and Adverse Events: A Collection of Vignettes

      Abstract

      Background

      Oversights in the physical examination are a type of medical error not easily studied by chart review. They may be a major contributor to missed or delayed diagnosis, unnecessary exposure to contrast and radiation, incorrect treatment, and other adverse consequences. Our purpose was to collect vignettes of physical examination oversights and to capture the diversity of their characteristics and consequences.

      Methods

      A cross-sectional study using an 11-question qualitative survey for physicians was distributed electronically, with data collected from February to June of 2011. The participants were all physicians responding to e-mail or social media invitations to complete the survey. There were no limitations on geography, specialty, or practice setting.

      Results

      Of the 208 reported vignettes that met inclusion criteria, the oversight was caused by a failure to perform the physical examination in 63%; 14% reported that the correct physical examination sign was elicited but misinterpreted, whereas 11% reported that the relevant sign was missed or not sought. Consequence of the physical examination inadequacy included missed or delayed diagnosis in 76% of cases, incorrect diagnosis in 27%, unnecessary treatment in 18%, no or delayed treatment in 42%, unnecessary diagnostic cost in 25%, unnecessary exposure to radiation or contrast in 17%, and complications caused by treatments in 4%. The mode of the number of physicians missing the finding was 2, but many oversights were missed by many physicians. Most oversights took up to 5 days to identify, but 66 took longer. Special attention and skill in examining the skin and its appendages, as well as the abdomen, groin, and genitourinary area could reduce the reported oversights by half.

      Conclusions

      Physical examination inadequacies are a preventable source of medical error, and adverse events are caused mostly by failure to perform the relevant examination.

      Keywords

      Clinical Significance
      • Most errors in the physical examination that lead to consequences are related to not performing an examination.
      • Failure to undress the patient and examine the skin is a frequent cause of error.
      • In a patient with abdominal pain, failure to examine the groin, rectal area, and hernia orifices can have dire consequences.
      SEE RELATED ARTICLE p. 1263
      According to the Institute of Medicine's report entitled “To Err is Human,”
      • Kohn K.T.
      • Corrigan J.M.
      • Donaldson M.S.
      To Err Is Human: Building a Safer Health System.
      medical errors cause nearly 100,000 deaths per year. The causes are systemic problems of inadequate organization, a culture of nondisclosure, and cognitive diagnostic errors.
      • Kassirer J.P.
      • Kopelman R.I.
      Cognitive errors in diagnosis: instantiation, classification, and consequences.
      • Graber M.L.
      • Franklin N.
      • Gordon R.
      Diagnostic error in internal medicine.
      • Singh H.
      • Graber M.L.
      • Kissam S.M.
      • et al.
      System-related interventions to reduce diagnostic errors: a narrative review.
      A potentially important type of error that has been given meager attention is deficiencies in physical examination.
      The high-tech transformation of medical care has resulted in diminishing direct patient-physician interaction. Hospitalists in America might spend only 18% of their on-duty time in direct patient care,
      • O'Leary K.J.
      • Liebovitz D.M.
      • Baker D.W.
      How hospitalists spend their time: insights on efficiency and safety.
      and duty-hour restrictions have resulted in Internal Medicine interns spending on average only 12% of their time with patients but 40% of their time on computer-related tasks.
      • Block L.
      • Habicht R.
      • Wu A.W.
      • et al.
      In the wake of the 2003 and 2011 duty hour regulations, how do internal medicine interns spend their time?.
      Diminished focus on the physical examination may result in important errors. We asked physicians to contribute clinical vignettes of oversights and errors in physical examination and adverse consequences that resulted from them. This database was created to identify the diverse types and characteristics of errors that can be made relating to the physical examination.

      Methods

      We designed an 11-question, qualitative survey for physicians, who were asked to send us vignettes of known instances of oversights in physical examination and to answer related multiple choice questions. The study was approved by the Stanford University Institutional Review Board; the detailed instructions to the respondent and the questionnaire can be found online at www.surveymonkey.com/s/8S6DL7V.
      A link to the questionnaire was sent to approximately 5000 physicians of diverse specialties using a commercial medical e-mail marketing service (MMS Inc, Woodale, Ill), with an estimated 2800 of these having teaching affiliations. In addition, we used social media sites to disseminate the link, and we encouraged physicians to share the link. There were no limitations regarding type of specialty and clinical practice setting.
      Data were gathered from February to June of 2011. Each entry was reviewed by 2 physicians. We excluded: entries that did not form a vignette (eg, “residents don't do rectal exams often enough”); entries missing critical information to form a vignette (eg, a failure to state what precisely was omitted/misinterpreted); entries with 2 or more vignettes combined when it became impossible to parse out which one was being addressed in the multiple choice questions. We corrected a response only when the answer to a multiple choice question clearly contradicted the vignette, suggesting the respondent selected the wrong box (eg, the narrative describes a missed hernia in a patient with pain because the abdominal examination was not done, but the respondent ticks “finding elicited but misinterpreted” in lieu of “failure to do relevant exam”).

      Results

      Of the 263 responses received, 55 were excluded; of the 208 remaining responses, 27 were corrected by the criteria described in Methods.
      Sixty-three percent of vignettes reported that the oversight was caused by a failure to perform the physical examination; 14% reported that the correct physical examination sign was elicited but misinterpreted. Eleven percent reported that the relevant sign was missed or not sought, and 12% reported “other” as the cause of the deficiency.
      Consequence of the physical examination inadequacy included missed or delayed diagnosis in 76% of cases, incorrect diagnosis in 27%, unnecessary treatment in 18%, no or delayed treatment in 42%, unnecessary diagnostic cost in 25%, unnecessary exposure to radiation or contrast in 17%, and complications caused by treatments in 4%.
      The person thought responsible for the oversight was most often an intern or resident (reported in 95 of 208 cases or 46%), a primary care physician (84, 40%), a specialist (79, 40%) or fellow (18, 9%). Though there was no multiple choice option available to implicate one's self as the person responsible, 9 responders (4%) indicated themselves as the physician responsible.
      The number of physicians thought to have missed an important aspect of the examination is shown in Figure 1. The oversight was typically discovered within 5 days (Figure 2). When participants were asked to estimate what percentage of practicing physicians have made a similar error to the one described, they estimated it to be >95% in 43 instances (20%), 50-95% in 42 instances (20%), and 5-50% in 78 oversights (37.5%), and less than 5% in 28 instances (28%).
      Figure thumbnail gr1
      Figure 1Distribution of number of overlookers for 208 oversights in physical exam.
      Figure thumbnail gr2
      Figure 2Distribution of time to discovery for 208 oversights in physical exam.
      The list of findings overlooked is long and diverse, but those that were missed more than 5 times included abdominal mass/organomegaly (n = 21, including 3 pregnancies and 2 distended bladders), diagnostic skin finding (n = 15, such as café au lait spots, neurfibroma, erythema migrans, syphilitic lesions, and meningococcemia lesions but not including herpes zoster), neurologic findings (n = 18), murmurs/rubs (n = 13, including 4 missed aortic stenosis, 3 missed pericardial rubs), lymphadenopathy (n = 10), groin hernia (n = 10) or scrotal/testicular pathology (n = 6), signs of peritonitis (n = 10), breast masses (n = 9), fracture or orthopedic finding (n = 9), congestive heart failure (n = 8), absent or abnormal pulses (n = 6), wound or ulcer (n = 6), bruising (n = 6), and herpes zoster (n = 5).
      Forty-seven oversights involved the skin and its appendages including the breast, 37 were related to the abdominal examination, 37 involved the cardiovascular system, and 36 involved the groin/genital/rectal area. Supplementary Table 1 (available online) lists all items that were missed.

      Discussion

      Recent publications describe the decline of physical examination skills.
      • Feddock C.A.
      The lost art of clinical skills.
      • Rahmani S.
      • Ring B.N.
      • Lowe R.
      • et al.
      A pilot study assessing knowledge of clinical signs and physical examination skills in incoming medicine residents.
      • Willett L.L.
      • Estrada C.A.
      • Castiglioni A.
      Does residency training improve performance of physical examination skills?.
      • Sharma S.
      A single-blinded, direct observational study of PGY-1 interns and PGY-2 residents in evaluating their history-taking and physical-examination skills.
      • Jauhar S.
      The demise of the physical examination.
      • Ortiz-Neu C.
      • Walters C.A.
      • Tenenbaum J.
      • Colliver J.A.
      • Schmidt H.J.
      Error patterns of 3rd-year medical students on the cardiovascular physical examination.
      Our study highlights the consequences and suggests that many adverse events are preventable. Our survey suggests that the major cause for error is simply that the examination is not performed.
      • Ortiz-Neu C.
      • Walters C.A.
      • Tenenbaum J.
      • Colliver J.A.
      • Schmidt H.J.
      Error patterns of 3rd-year medical students on the cardiovascular physical examination.
      • Bordage G.
      Why did I miss the diagnosis? Some cognitive explanations and educational implications.
      In addition to diagnostic consequences, approximately half of the vignettes report treatment consequences. Most oversights pertained to a limited number of overlookers, suggesting that some errors may be remedied if several people examine the patient. Although the majority of the errors were corrected within 5 days, even a delay of 1 hour might affect patient outcomes.
      Examining a patient presenting with a complaint (as opposed to the “routine physical”) is a low-cost procedure that, when done with skill, can avoid the majority of oversights listed. Many diseases involving the skin or the nervous system cannot easily be diagnosed except by the examination, and for others the appropriate diagnostic test is indicated by the examination. The drop-down boxes of the electronic medical record deceptively suggest every patient has been thoroughly examined (and therefore can be billed), but it will be the responsibility of educators and professional organizations to make sure the electronic medical record truthfully reflects what was done.
      A short checklist is suggested by our study: physicians should seek full exposure of the patient; there must be a mandate to examine hernial orifices and the genital and rectal areas in acutely ill patients or with pain. Pain should prompt a search for the lesions of shingles. Non-neurologists need a sound neurologic skill set because imaging does not show the functional deficits resulting from a lesion seen. For diseases like Wernicke's encephalopathy or Bell's palsy, imaging may not be diagnostic. Finally, there should be a greater emphasis on actually performing the examination. In short, physicians in training must be taught and evaluated at the bedside to diminish this kind of error.
      Our survey was not designed to determine prevalence but to generate an anthology of physical examination oversights along with their characteristics. The vignettes are subject to recall and response biases. We set no time limitation on reports and did not ask responders to specify where they practiced medicine. Finally, even though we contacted thousands of physicians, only a small minority contributed vignettes, suggesting a cultural reluctance to admit and share errors, unlike for example in the aviation industry. We as physicians might work in an “ignorance trap” in which our physical examination oversights are rarely reported back to us.
      Diligence in actually teaching and performing the physical examination and continuing efforts to improve bedside skills would diminish one kind of medical error and its consequences for the patient.

      Acknowledgment

      The authors thank Ralph Horwitz, MD, for his encouragement of the First Stanford Symposium on Bedside Medicine in 2009, and for his helpful discussions in planning this study.

      Supplementary Data

      Supplementary Table 1Complete List of Items Missed as Reported in Returned Questionnaires
      Missed skin finding of subcutaneous emphysema
      Missed pulse absence in ischemic foot
      Missed pregnancy with twins before hysterectomy
      Missed hip fracture labeled as right lower quadrant pain
      Missed Bell's palsy
      Missed liver mass, abdominal mass in cholangiocarcinoma
      Missed funduscopic finding of cupping
      Missed strangulated groin hernia in small bowel obstruction
      Missed incarcerated femoral hernia
      Missed crackles in a patient with pulmonary edema
      Missed finger pressure necrosis on microvascular free flap
      Missed peritoneal signs and free air on plain film
      Missed peritonitis in patient with gangrenous perforated gall bladder
      Missed adenopathy and therefore chronic lymphocytic leukemia
      Missed thyromegaly in patient with tachycardia
      Missed strangulated hernia
      Missed fungating breast mass
      Missed pelvic examination and therefore missed tubo-ovarian abscess
      Missed pregnancy by missed gynecologic examination in patient with seizures
      Missed pyoderma gangrenosum in skin
      Missed Fournier's gangrene in groin—no genital examination
      Missed clonus and hyperreflexia
      Missed abdominal examination finding of tenderness and Grey Turner signs
      Missed neurofibroma and café au lait spots
      Missed large abdominal mass
      Missed heart failure signs of cardiomyopathy after flu in a young person
      Missed pulse extremity examination, missed Buerger's
      Missed testicular mass in teen
      Missed massive splenomegaly
      Missed second cervix
      Missed abrasion on forehead, clue to subdural
      Missed bruising signs of abuse in child
      Missed prostate mass with elevated prostate-specific antigen
      Missed decreased pulses, arterial occlusion in elderly man after hip fracture
      Missed strangulated femoral hernia in 88-year-old with emesis
      Missed loud bruit in patient with renal failure and hypertension
      Missed ruptured spleen after trauma
      Missed ectopic pregnancy because no pelvic examination done
      Missed obvious congestive heart failure (CHF) signs labeled as bronchitis
      Missed rotatory and vertical nystagmus in patient with basilar artery aneurysm
      Missed abdominal examination, old scar mislabeled as hernia, scar and patient operated on for “recurrent” hernia and nothing found
      Missed pulses in patient with peripheral vascular disease
      Missed tuberculosis signs in chest
      Missed vital sign of tachypnea on first visit in a patient later found with bacteremic pneumonia
      Missed adenopathy in lymphoma
      Missed clavicle fracture, labeled “rule out myocardial infarction”
      Missed the tan of hemochromatosis
      Missed femoral fracture
      Missed acute myocardial infarction by focusing on neck pain, ear pain
      Missed hyperreflexia and cord compression in Potts disease
      Missed rectal and missed prostatic abscess
      Missed supraclavicular mass in lung cancer
      Missed splenomegaly and delayed diagnosis of chronic myelogenous leukemia
      Missed psoriasis and its signs
      Missed groin cellulitis
      Missed dislocated shoulder on examination
      Missed adenopathy in germ cell tumor
      Missed marked pallor in elderly anemic
      Missed pulsatile abdominal aneurysm
      Missed adenopathy in patient with Waldenstrom's disease
      Missed penetrating foreign body in vaginal fistula
      Missed gastric bypass scar in patient with malnutrition and beriberi
      Missed signs of CHF in a young patient
      Missed femoral hernia in patient with vomiting
      Missed signs of hypothyroidism and neck scar in unresponsive patient
      Missed retinal lesions in a child with poor vision
      Missed signs of myocarditis and CHF, especially the tachycardia in a child
      Misconstrued bruit from an aortofemoral bypass as a cardiac murmur
      Missed obvious CHF signs
      Missed obvious pregnancy and labor
      Missed huge spleen in cirrhosis
      Missed previous appendectomy scar and made diagnosis of appendicitis again
      Missed ulnar nerve transection after trauma
      Missed male breast mass
      Missed distended bladder
      Missed incarcerated hernia
      Missed breast mass and metastases
      Missed zoster presenting as abdominal pain
      Missed femoral hernia
      Missed orchitis and diagnosed it as hernia
      Missed aortic stenosis murmur preoperatively
      Missed breast mass
      Missed anus present in patient stated to have abdomino-perineal resection, when they had Hartman procedure
      Missed prolapsing rectal cancer, rectal examination not done
      Missed incarcerated groin hernia
      Missed bruises of abuse
      Missed large melanoma over scapula
      Missed hoarseness, puffiness, and signs of hypothyroidism
      Missed decubitus ulcer causing “back pain”
      Missed leg ulcers and sores as a cause of fever in alcoholic
      Missed skin findings of secondary syphilis
      Missed hip fracture in patient who could not walk
      Missed gouty nodules
      Missed breast mass
      Missed mucor wound on hand in immunocompromised patient
      Missed zoster in patient with chest pain
      Missed foot ulcer in diabetic with fever
      Missed signs of Parkinson's in elderly being worked up for falls
      Missed lymph node in a patient with breast cancer
      Missed abdominal mass lymphoma in patient complaining of pain
      Missed skin ash leaf macule in child with hypertension
      Missed anterior cruciate ligament tear with classic signs
      Missed giant ovarian cyst, labeled as ascites
      Missed giant ovarian cyst again thought to be ascites
      Missed loud murmur of ruptured mitral valve chordae tendinae
      Missed murmur and signs of subacute bacterial endocarditis
      Missed cutaneous abscess in compromised patient with fever
      Missed obvious CHF in 33-year-old with cardiomyopathy
      Missed appendicitis signs
      Missed strangulated hernia
      Missed Down's syndrome on examination in 6 month old
      Missed acute central vein occlusion in patient with decreased vision—no fundoscopy done
      Missed anal cancer said to be hemorrhoids
      Missed peritonitis signs in patient with Crohn's
      Missed dentures in mouth during intubation
      Missed significant murmur of mitral stenosis, called it aortic stenosis
      Missed abdominal mass turned out to be lymphoma
      Missed aortic stenosis in preoperative examination
      Missed scrotal mass until after surgery for abdominal mass. Was testicular tumor with metastases
      Missed supraclavicular nodes in patient with lung cancer
      Missed hyperreflexia and clonus from epidural abscess
      Missed adenopathy in non-Hodgkin's lymphoma with fever of unknown origin—called a hernia
      Missed neck nodes
      Missed pelvic inflammatory disease because no pelvic examination done
      Missed gunshot entrance wound in emergency room
      Missed large abdominal masses in patient with bloating
      Missed pregnancy in patient with large belly
      Missed signs of CHF in patient presenting with “scrotal swelling”
      Missed liver laceration after trauma because focus on head
      Missed enlarged tonsil that was cancer
      Missed clavicle fracture in patient with syncope
      Missed ecchymosis in patient from a fall, and the left arm pain assumed to be cardiac
      Missed contact dermatitis
      Missed constrictive pericarditis signs
      Missed breast mass in patient with shoulder pain
      Missed breast mass in patient with deep vein thrombosis
      Missed rapid growth in head circumference
      Missed splinters and signs of subacute bacterial endocarditis
      Missed systolic murmur cardiac, labeled carotid bruits
      Missed pericardial rub and pericarditis
      Missed zoster rash
      Missed hip disease as a cause of joint pain
      Missed femoral pathologic fracture in patient with knee pain
      Missed large liver in patient with diabetic ketoacidosis
      Missed zoster as cause of chest pain
      Missed watch battery in umbilicus in child
      Missed purulence in tonsils
      Missed normal ear examination labeled as perforation by not doing pneumatic otoscopy
      Missed breast mass in patient with chest pain and metastasis
      Missed pregnancy, called it constipation
      Missed meningococcemia skin lesion in patient with fever
      Missed CHF findings in patient with postpartum cardiomyopathy
      Missed hoarseness and laryngeal mass in patient labeled asthma
      Missed rectal mass by gastrointestinal consultant after primary care physician feels mass—sigmoidoscopy negative, but tumor develops
      Missed appendicitis by focus on chest
      Missed rales and crackles
      Missed obvious pleural effusion, no examination
      Missed signs of myasthenia in patient with weight loss
      Missed signs of bowel obstruction
      Missed signs of mitral regurgitation from torn leaflet
      Missed hepatomegaly and hepatocellular carcinoma in patient with vague symptoms
      Missed metastatic node from breast cancer in patient with weight loss
      Missed stone in urethra causing recurrent urinary tract infection
      Missed pelvic examination in adolescent and missed pelvic inflammatory disease
      Missed radiculopathy causing abdominal pain
      Missed signs of peritonitis
      Missed fungating breast mass
      Missed abdominal mass in patient with back pain
      Missed pelvic examination and missed procidentia
      Missed skin signs of calcinosis in patient with mixed connective tissue disease
      Missed breast mass in patient being worked up for metastasis
      Missed skin erythema migrans in patient with Bell's palsy
      Missed abnormal pulses of combined aortic stenosis/aortic regurgitation and focused on treating high blood pressure and pulse pressure
      Missed aortic stenosis murmur
      Missed abdominal mass, expanding aortic aneurysm in patient with abdominal pain
      Missed pericardial friction rub in chest pain
      Missed nasal septal hematoma
      Missed scrotal infection in diabetic
      Missed Korsakoff's signs in many neurologic examinations
      Missed zoster in patient with chest pain who had coronary angiogram
      Missed pelvic examination and missed ovarian cyst
      Missed adenopathy and hepatomegaly in patient with anemia and weight loss
      Missed inflammatory knee effusion in intensive care unit patient with fever
      Missed distended bladder labeled abdominal mass
      Missed rectal examination and therefore missed prostatitis
      Missed doing pulsus paradoxus in patient with tamponade
      Missed abnormal decreased pulse and blood pressure in one arm
      Missed purulence around IV catheter as cause of fever
      Mistaken diagnosis of peritonitis, bias from x-rays showing pneumatosis intestinalis
      Missed lytic lesions as cause of left-sided weakness in limbs
      Missed CHF signs
      Missed purulence at bone marrow biopsy site in patient with fever
      Missed clubbing in patient with shoulder pain who has lung cancer
      Missed hernia because of missed groin examination
      Missed edema from hypoproteinemia labeled CHF
      Missed peritonitis and perforation
      Missed murmur of critical aortic stenosis
      Missed butterfly bruises of factitious injury
      Missed neurogenic bladder
      Missed costochondritis in patient labeled as rule out myocardial infarctions
      Missed epididymitis in patient with abdominal pain
      Missed scrotal examination
      Missed erythema migrans in patient with fever and headache
      Missed large abdominal mass on both pelvic and seated abdominal examination
      Missed embolic arterial occlusion
      Missed uremic calciphylaxis in patient on dialysis

      References

        • Kohn K.T.
        • Corrigan J.M.
        • Donaldson M.S.
        To Err Is Human: Building a Safer Health System.
        National Academy Press, Washington, DC1999
        • Kassirer J.P.
        • Kopelman R.I.
        Cognitive errors in diagnosis: instantiation, classification, and consequences.
        Am J Med. 1989; 86: 433-441
        • Graber M.L.
        • Franklin N.
        • Gordon R.
        Diagnostic error in internal medicine.
        Arch Intern Med. 2005; 165: 1493-1499
        • Singh H.
        • Graber M.L.
        • Kissam S.M.
        • et al.
        System-related interventions to reduce diagnostic errors: a narrative review.
        BMJ Qual Saf. 2012; 21: 160-170
        • O'Leary K.J.
        • Liebovitz D.M.
        • Baker D.W.
        How hospitalists spend their time: insights on efficiency and safety.
        J Hosp Med. 2006; 1: 88-93
        • Block L.
        • Habicht R.
        • Wu A.W.
        • et al.
        In the wake of the 2003 and 2011 duty hour regulations, how do internal medicine interns spend their time?.
        J Gen Intern Med. 2013; 28: 1042-1047
        • Feddock C.A.
        The lost art of clinical skills.
        Am J Med. 2007; 120: 374-378
        • Rahmani S.
        • Ring B.N.
        • Lowe R.
        • et al.
        A pilot study assessing knowledge of clinical signs and physical examination skills in incoming medicine residents.
        J Grad Med Educ. 2010; 2: 232-235
        • Willett L.L.
        • Estrada C.A.
        • Castiglioni A.
        Does residency training improve performance of physical examination skills?.
        Am J Med Sci. 2007; 333: 74-77
        • Sharma S.
        A single-blinded, direct observational study of PGY-1 interns and PGY-2 residents in evaluating their history-taking and physical-examination skills.
        Perm J. 2011; 15: 23-29
        • Jauhar S.
        The demise of the physical examination.
        N Engl J Med. 2006; 354: 548-551
        • Ortiz-Neu C.
        • Walters C.A.
        • Tenenbaum J.
        • Colliver J.A.
        • Schmidt H.J.
        Error patterns of 3rd-year medical students on the cardiovascular physical examination.
        Teach Learn Med. 2001; 13: 161-166
        • Bordage G.
        Why did I miss the diagnosis? Some cognitive explanations and educational implications.
        Acad Med. 1999; 74: S138-S143

      Linked Article