Despite several approaches and the implementation of different strategies, injuries continued to be missed. Introduction of shift systems following implementation of the European Working Time Directive, non-availability of senior cover, lack of radiological reporting in casualty are the confounding factors. With the introduction of the foundation system for medical postgraduate training in the UK, the number of inexperienced staff and related diagnostic errors in acute trauma are expected to rise significantly. This study showed that a morning trauma meeting to review admitted patients as well as orthopaedic referrals is an effective risk-management solution to the early detection of missed and wrong diagnoses.
Making the correct diagnosis and imparting optimum treatment not only improve patient care but also provide medicolegal protection. Wardrope and Chennells1
reported 6.2% overall prevalence of errors out of which 1% required alteration of management. Williams et al.2
observed an 18% false positive rate. In a study by Kremli,3
there was a 6% diagnostic failure rate (638 patients). Morton5
noted 17.2% incorrect diagnoses and 12% incorrectly treated patients in a cohort of 250 patients. Juhl et al.6
noticed a 2.2% missed injury rate in 783 patients, Thomas et al.7
found a 2.8% error rate, while Vincent et al.8
found as high as 35% overall error rate. Our series revealed 12.6% false positive and 4% false negative rates. Optimum management of patients in accident and emergency plays a vital role in the smooth running of orthopaedic fracture clinics by avoiding unnecessary follow-up and providing a genuine appointment to appropriate patients.
The higher incidence of missed hand and foot fractures are a common source of medical litigation; this is often due to incomplete examination and inexperience of junior staff in interpreting X-rays. On the other hand, distal radial and scaphoid fractures were often overdiagnosed. Other injuries such as talar neck fractures and displaced intra-articular calcaneal fractures which required operative intervention were overlooked because of patient's state of intoxication as well as other distracting injuries.
We believe that a higher false negative rate in small accident and emergency units could be attributed to the non-availability of out-of-hours senior cover for final radiological interpretation, as the majority of cases were seen by SHOs. However, there can be several variables relating to uncontrollable circumstances leading to diagnostic errors. We recommend good clinical routine, careful serial examination of patients at initial presentation, systematic radiographic evaluation, awareness of common diagnostic pitfalls, proper documentation and effective handover to minimise the risk of missing injuries.9
Radiologist review of the X-rays10,11
on the same day and on-site out-of-hours senior cover can reduce inappropriate referrals to busy specialties. Cost reduction incurred by multiple follow-ups of inappropriate referrals in the fracture clinic should be considered. The medicolegal significance of false positive and false negative diagnoses is immense. False positive diagnosis can unduly enhance patient and parental anxiety.
We believe a higher false positive rate indicates inappropriate referrals to fracture clinics, although, relatively inexperienced junior doctors tend to play safe in the absence of senior cover. To generate a consensus and uniformity across the UK in treating common orthopaedic trauma, common guidelines for primary management of acute orthopaedic and trauma conditions could be of great help (). This will additionally serve as a good teaching tool.
Template for common guidelines for primary management of acute orthopaedic and trauma conditions
With recent advances in digital radiography, the presence of a senior doctor is not always required. Evidence suggests that reliability, sensitivity, and specificity of the digitised radiographs were not decreased after transmission by E-mail. Teleconsultation using digital camera images sent by E-mail is a valid and reliable approach.12,13