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Diagnostic errors in orthopaedics are usually caused by missing a fracture or misreading radiographs. The aim of this study was to document the pick-up rate of the wrong diagnoses by reviewing X-rays and casualty notes in the next-day trauma meeting.
The casualty notes and radiographs of 503 patients were prospectively reviewed in the daily trauma meeting between August 2002 and December 2002 in a district general hospital. The relevant data were collected and analysed by a single assessor.
The false positive rate for making an orthopaedic diagnosis was 12.6% (i.e.) diagnosing a fracture, when none existed). The false negative (missing) rate was 4%, while 2.4% incidental findings were missed, or at least not documented, after reading the X-rays. There were 7.8% wrong diagnoses made. The majority of the patients were seen by the senior house officers.
The medicolegal significance of false negative diagnosis is obviously greater. In a busy emergency department, where a large number of patients are seen, there is a greater risk. This study shows the importance in a small-to-medium sized accident and emergency unit as well, where there is no senior cover available out-of-hours for final radiological interpretation. A morning trauma meeting which covers reviewing admitted patients as well as non-admission orthopaedic referrals has an effective risk management solution to early detection of missed and wrong diagnoses.
Musculoskeletal injuries present major diagnostic and therapeutic challenges. Despite development of major trauma centres, multispecialty team-work and wide application of ATLS principles, some of these injuries continue to be missed. Non-availability of senior cover, varied experience of junior doctors in interpretation of radiographs, lack of comprehensive secondary survey, presentation of complex patients during change of shift are the vital factors behind such diagnostic errors.1–3 Diagnostic failure rates vary from 2.2% to as high as 35% in various reported series.1–4 While radiologists report on most radiographs from the emergency department there is commonly a delay of up to a week. Many of the orthopaedic departments across the UK have a morning trauma meeting, reviewing acute trauma admissions to discuss their management. However, this does not include those orthopaedic referrals which have been discharged from the emergency department. 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. The aim of this study was to analyse the pick-up rate of the missed and wrong diagnoses at an early stage by reviewing X-rays and casualty notes of all the orthopaedic referrals in the next-day trauma meeting along with acute orthopaedic admissions, and to assess the effect of early review of orthopaedic referrals on the clinical risk management.
Between August 2002 to December 2002, 503 patients referred from an intermediate-sized emergency department of a district general hospital in the UK were prospectively reviewed. The casualty notes and plain radiographs were presented by the on-call senior house officer (SHO) in the morning trauma meetings and discussed by the members of the orthopaedic department. Some of SHOs in the accident and emergency department had no previous orthopaedic experience. They were asked to keep notes and plain radiographs of all the patients seen and referred to fracture clinic in a separate box.
The annual attendance at this emergency department was 44,000 patients at the time of the study, consistent with any medium-sized accident and emergency department in the UK. This hospital covers all the specialties except for neurosurgery and plastic surgery. Monday morning meetings lasted for 15–20 min due to the greater number of cases collected over the weekend period. The time spent in Tuesday to Friday morning meetings was 8–10 min. These times were in addition to the time spent in the trauma meetings discussing admitted orthopaedic patients.
Further data regarding patient demographics, mechanism and time of injury, time of presentation, orthopaedic diagnosis and missed injuries were noted. The ‘missed injury’ was defined as an injury not diagnosed in the casualty department at the time of first clinical and or radiological examination. On the basis of the above information, false positive (over diagnosed) and false negative (missed injuries) rates for making an orthopaedic diagnosis were calculated. Diagnostic error was considered significant if it necessitated a change in the treatment including follow-up and recall of the patient. The implication of unnecessary follow-up organised by inexperienced SHOs on utilisation of fracture clinic time and resources were noted.
A total of 503 patients were enrolled in this study, which were considered as ‘not for admission’ by the emergency SHOs and referred to the next-day trauma meeting and next-day fracture clinic. Of these patients, 60% were male and 40% female, with 25% in the age group 10–20 years. About 80% of the patients presented on the same day of their injury. In the series, there were 390 fractures, 15 subluxations or dislocations and 48 soft-tissue injuries including ligament disruption, haemarthrosis, lacerations, and tendon injuries. Diagnostic discrepancy was found in 37 patients where either an over-enthusiastic diagnosis was made or injuries were missed.
Table 1 shows a breakdown of the missed injuries and the circumstances leading to the problem. Common reasons for missed or wrong diagnoses were either radiological misinterpretation or inadequate physical examination. Other factors were inadequate history or inadequate radiographic views. The false positive rate for making an orthopaedic diagnosis was 12.6% (i.e.) diagnosing a fracture when none existed). The false negative rate was 4%, while 2.4% incidental findings were missed, or at least not documented, after reading the X-rays. There were 7.8% wrong diagnoses made. Four patients were recalled, two of whom needed surgery. Review at morning meetings identified 50 patients with soft-tissue injuries who were given fracture clinic appointments which were thought to be unnecessary (10% inappropriate orthopaedic referrals).
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 (Table 2). This will additionally serve as a good teaching tool.
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.
The medicolegal significance of false negative diagnosis is obviously of concern. In a busy emergency department, where a large number of patients are seen, there is a greater risk. This study shows the importance in small-to-medium sized accident and emergency units as well, when there is no out-of-hours senior cover available for final radiological interpretation. A morning trauma meeting which covers reviewing admitted patients as well as non-admission orthopaedic referrals is an effective risk-management solution to the early detection of missed and wrong diagnoses.