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 <.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.
Keywords
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Article info
Publication history
Published online: March 30, 2017
Footnotes
Funding: This project is supported with resources and the use of facilities at the Houston VA Health Services Research and Development Center of Excellence (HFP90-020) at the Michael E. DeBakey VA Medical Center, Houston, Texas. Murphy is additionally funded by an Agency for Healthcare Research & Quality Mentored Career Development Award (K08-HS022901) and Singh is supported by the VA Health Services Research and Development Service (CRE12-033; Presidential Early Career Award for Scientists and Engineers USA 14-274), the VA National Center for Patient Safety and the Agency for HealthCare Research and Quality (R01HS022087 and R21HS023602). This work is supported in part by the Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety (CIN13-413). These funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript.
Conflict of Interest: The authors have no financial disclosures to report.
Authorship: All authors had access to the data and a role in writing the manuscript. VB and DRM had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.
Identification
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Published by Elsevier Inc.
