title: Diagnostic error in the Emergency Department: follow up of patients with minor trauma in the outpatient clinic.
abstract: BACKGROUND
  The Emergency Department (ED) is prone to diagnostic error. Most frequent diagnostic errors involved "minor" trauma. Our goal was to determine how frequently a missed diagnosis was detected during follow up and to determine the frequency and causes of primary missed diagnosis and diagnostic error.
  
  
  METHODS
  A retrospective single centre study review, during 6 months including all patients presenting to the outpatient clinic after ED admission with a minor trauma. We defined primary missed diagnosis versus diagnostic error. Demographic data were collected in Excel file and analyzed using Χ2and unpaired T-test.
  
  
  RESULTS
  Inclusion of 56 patients leading to 57 missed diagnoses representing 1.39% of all minor trauma patients presenting to the ED. History and physical examination notes were incomplete or inadequate in respectively 17/56 and 20/56. Most frequently missed diagnoses were ankle (13/57), wrist (8/57) and foot (7/57) fractures. Causes for diagnostic error could be categorized into two main groups: failure to perform adequate history taking and/or physical examination and failure to order or correctly interpret technical investigation. In 6 cases (0.14%) diagnostic error was confirmed. All other cases were defined as primary missed diagnosis.
  
  
  CONCLUSIONS
  Emergency physicians have to remain vigilant to prevent and avoid primary missed diagnosis (PMD) and diagnostic error (DE), certainly in case of minor trauma patients, representing a large proportion of ED patients. We observed a prevalence of 1.39% of missed diagnoses within a six month study period. This is comparable to previous studies (1% ). However in our study both primary missed diagnoses and DE were included. Using this definition we saw that only one case could be attributed to negligence and DE had a prevalence of 0.14% (6 cases). X-rays remain the mainstay investigation for minor trauma patients, however in certain selected cases (pelvic and spinal trauma) we advise early CT-scan.Follow up in an outpatient clinic or other forms of planned follow up have to be provided and help to reduce PMD and DE.
  
  
  CONCLUSIONS
  Both primary missed diagnosis and diagnostic error have relatively low prevalence but have a serious impact on patients, hospitals and medical services. Planned follow up after adequate explanation can help to prevent diagnostic error and detect primary missed diagnosis, thereby reducing time to final diagnosis and risks for medico legal litigation. Reassessment of diagnostic error on a timely basis can be used as a key performance indicator in a quality assessment program.
authors.affiliation: Department of Anesthesiology, Critical and Emergency Medicine and Pain Therapy, Ziekenhuis Oost Limburg Genk, Schiepsebos 11, 3600, Genk, Belgium. pieterjanmoonen@hotmail.com.|ᅟ, Ieperstraat 43, 2300, Turnhout, Belgium. pieterjanmoonen@hotmail.com.
authors.forename: Pieter-Jan
authors.initials: PJ
authors.lastname: Moonen
authors.affiliation: Department of General Surgery, Ziekenhuis Oost Limburg Genk, Schiepsebos 11, 3600, Genk, Belgium.
authors.forename: Luc
authors.initials: L
authors.lastname: Mercelina
authors.affiliation: Department of Anesthesiology, Critical and Emergency Medicine and Pain Therapy, Ziekenhuis Oost Limburg Genk, Schiepsebos 11, 3600, Genk, Belgium.
authors.forename: Willem
authors.initials: W
authors.lastname: Boer
authors.affiliation: Department of Anesthesiology, Critical and Emergency Medicine and Pain Therapy, Ziekenhuis Oost Limburg Genk, Schiepsebos 11, 3600, Genk, Belgium.
authors.forename: Tom
authors.initials: T
authors.lastname: Fret
mesh_terms: D000554:Ambulatory Care Facilities; D001530:Belgium; D003266:Continuity of Patient Care; D003951:Diagnostic Errors / Q000706:statistics & numerical data*; D004636:Emergency Service, Hospital; D005260:Female; D006801:Humans; D008297:Male; D012189:Retrospective Studies; D014947:Wounds and Injuries / Q000000981:diagnostic imaging* / Q000628:therapy
keywords: Diagnostic error; Emergency department; Fracture; Malpractice; Minor trauma; Primary missed diagnosis