title: Electronic health record-based surveillance of diagnostic errors in primary care.
abstract: BACKGROUND
  Diagnostic errors in primary care are harmful but difficult to detect. The authors tested an electronic health record (EHR)-based method to detect diagnostic errors in routine primary care practice.
  
  
  METHODS
  The authors conducted a retrospective study of primary care visit records 'triggered' through electronic queries for possible evidence of diagnostic errors: Trigger 1: A primary care index visit followed by unplanned hospitalisation within 14 days and Trigger 2: A primary care index visit followed by ≥1 unscheduled visit(s) within 14 days. Control visits met neither criterion. Electronic trigger queries were applied to EHR repositories at two large healthcare systems between 1 October 2006 and 30 September 2007. Blinded physician-reviewers independently determined presence or absence of diagnostic errors in selected triggered and control visits. An error was defined as a missed opportunity to make or pursue the correct diagnosis when adequate data were available at the index visit. Disagreements were resolved by an independent third reviewer.
  
  
  RESULTS
  Queries were applied to 212 165 visits. On record review, the authors found diagnostic errors in 141 of 674 Trigger 1-positive records (positive predictive value (PPV)=20.9%, 95% CI 17.9% to 24.0%) and 36 of 669 Trigger 2-positive records (PPV=5.4%, 95% CI 3.7% to 7.1%). The control PPV of 2.1% (95% CI 0.1% to 3.3%) was significantly lower than that of both triggers (p≤0.002). Inter-reviewer reliability was modest, though higher than in comparable previous studies (к=0.37 (95% CI 0.31 to 0.44)).
  
  
  CONCLUSIONS
  While physician agreement on diagnostic error remains low, an EHR-facilitated surveillance methodology could be useful for gaining insight into the origin of these errors.
authors: Houston VA HSR&D Center of Excellence, Michael E DeBakey Veterans Affairs Medical Center, Houston, Texas, USA. hardeeps@bcm.edu
authors: Hardeep
authors: H
authors: Singh
authors: Traber Davis
authors: TD
authors: Giardina
authors: Samuel N
authors: SN
authors: Forjuoh
authors: Michael D
authors: MD
authors: Reis
authors: Steven
authors: S
authors: Kosmach
authors: Myrna M
authors: MM
authors: Khan
authors: Eric J
authors: EJ
authors: Thomas
mesh_terms: D003951:Diagnostic Errors; D057286:Electronic Health Records; D006801:Humans; D008485:Medical Audit; D011320:Primary Health Care / Q000592:standards* / Q000706:statistics & numerical data; D012189:Retrospective Studies; D013781:Texas