Misdiagnosis is one of the costliest mistakes committed even by the best of physicians in routine practice. Most of these are preventable, while some are inevitable, making it important to demarcate and be alert to warning signs.

In spite of the tremendous change in medical practice witnessed over the past decade, with technology being incorporated into routine medical practice, misdiagnosis is still rampant and evident. The recent case of Ebola misdiagnosis in Texas leading to the entry of Ebola virus into the U.S shores strongly highlights the current susceptibilities of outpatient care to infection which makes it one of the biggest challenges medical professionals face on a daily basis.

The story so far

Thomas Eric Duncan succumbed to Ebola on October 8, 2014 due to misdiagnosis and mismanagement of the disease condition at that time. He was sent back home only with a regular course of antibiotics for his symptoms, being diagnosed and treated as flu. His symptoms persisted and he was brought back to the Dallas hospital in emergency. Even then, he was not given adequate care after which he was tested for Ebola virus and only much later put in isolation. After fighting for his life, he finally succumbed to Ebola. Following this mishap a thorough investigation followed.

The blame game started and the hospital authorities came out with various versions of the reason for misdiagnosis from blaming electronic medical software, to inaccurate history given by patient. This was the first case of Ebola to be diagnosed outside Africa, where over 3000 people have already lost their lives due to this deadly pathogen.

Mistakes in diagnosing Ebola were admitted to later by the Chief Clinical Officer for Texas Health Resources in testimony at a hearing. The hospital authorities acknowledged the error in diagnosis nearly 3 weeks after the patient’s death.

The blame game

A lot of questions have been put forward regarding the misdiagnosis, like delay in treatment and most importantly on why the patient was not isolated on suspicion of Ebola. This could be hazardous to public health as Ebola is a lethal virus. This case demonstrates how the use of electronic medical records can hamper accurate clinical decision making. This has resulted in widespread fear regarding safety and efficiency of outpatient care. Flaws were pointed out in the working and functioning of EMRs, as regards separation of workflow between the physician and nurse. The travel section data of a hospital is only present in the nursing section of the EMR for quick and easy administration of influenza vaccines. Later, this statement was withdrawn by the hospital authorities saying that the physician and nursing workflows are not separate and there is easy access to both.

Lessons to be learnt

This case presents a learning opportunity to the global medical fraternity. These errors are neither new nor restricted to rare diseases such as Ebola. Most times these diagnostic errors are not brought to light unless it involves a celebrity or an important person. According to studies, annually around 12 million people are misdiagnosed in outpatient care in US.

EMR systems are generally held responsible for the failure of medical system to understand and address the underlying factors contributing to such misdiagnosis. Inadequate design or implementation of data review and procedures are also key factors for such errors. EMRs also have user and operation difficulties.

It should be remembered that these EMRs are only tools to simplify our medical practice and in no way meant to replace the clinical skill and judgement of a physician. Technically, lack of alertness, awareness and lack of communication between nursing staff and physician are also equally responsible for such mishaps. These skills are far more necessary than data spewing machines. The advent of technology has reduced communications between physician and patient leading to such grave mistakes. Communication is one of the most important aspects of a good and successful medical practice.

The last word

To prevent such cases, it is important that EHRs have more innovation as regards to condition-specific templates, checkboxes, easy billing and documentation. All important data should be presented in an easy and comprehensible manner to prevent misdiagnosis. Lot of research still needs to be done to make these EMRs error free. Overlooking of information, especially the notes made by the nurse, needs to be addressed by physicians. Good verbal communication has to be there amongst the entire healthcare team so that flow of information is there in the
correct manner. This diagnostic error may have only affected one individual, but has made the global medical fraternity and patient community sit up and take notice of how change is not always for the better.

Contributed by Dr. Rachita Narsaria, MD

References

1. Capraro A, Stack A, Harper MB, Kimia A. Detecting unapproved abbreviations in the electronic medical record.Jt Comm J Qual Patient Saf. 2012;38:178-183.
2. Newman-Toker DE, Moy E, Valente E, Coffey R, Hines AL. Missed diagnosis of stroke in the emergency department: a cross-sectional analysis of a large population-based sample.Diagnosis. 2014;1:155-166.