Table 1

Examples of errors with reviewer agreement and the process breakdowns involved (all patients have been referred to as male, and ages have been masked).

CaseErrors
A non-English speaking patient presented with abdominal pain, and nurses documented vomiting with inability to tolerate oral intake. Laboratory revealed elevated liver function tests. No interpreter services were used, but the provider documented no nausea or vomiting, and referred the patient for elective outpatient cholecystectomy without performing an abdominal ultrasound. The patient returned the next day, and was diagnosed with choledocholithiasisProblems with history
Problems ordering diagnostic test for further work-up in the ED
Problems with timely follow-up of abnormal test result
Patient with history of prior cholecystectomy presented with left upper quadrant pain, nausea and vomiting, which were worse with eating. Liver function tests were elevated. A CT abdomen/pelvis was performed and read by radiology resident as duodenitis, and the patient was discharged with PCP follow-up. Postdischarge, the radiology attending reread the preliminary CT as choledocholithiasis, but the patient was not called back. The patient returned on his own a few days later with worsening symptomsProblems with diagnostic test (radiology over-read)
Problems with follow-up of abnormal test result
Patient with no medical history presented with 4 days of abdominal pain, nausea, vomiting and diarrhoea after eating fast food. Chief complaint in triage was ‘food poisoning’. Documented examination did not find lower abdominal tenderness. Laboratory showed leucocytosis with left shift, and right upper quadrant ultrasound was negative. He was discharged home with antibiotics for possible colitis without a follow-up plan. He returned with worsening pain few days later, and CT revealed ruptured appendicitisProblems with physical examination
Problems ordering diagnostic test for further work-up in the ED (CT scan)Problems scheduling appropriate follow-up (none given)
Patient with history of gallstone pancreatitis presented with right upper quadrant pain, nausea and vomiting. Laboratory revealed elevated liver function tests and normal WBC count, but with left shift. Patient was discharged from ED without imaging, but returned about a week later with worsening symptoms and new fever. Imaging revealed choledocholithiasis with cholangitisProblems ordering diagnostic test for further work-up in the ED
Problems with timely follow-up of abnormal test results
Patient with stage 4 colon cancer on chemotherapy presented with >1 week nausea, vomiting, diarrhoea and abdominal pain. No differential diagnosis recorded. Patient was given intravenous fluids and offered admission for intravenous hydration and intravenous antiemetics, but refused. Returned a few days later after an outpatient CT revealed small bowel obstruction. On return visit, a history of >1 week of minimal stool output and no flatus was elicited by the new care teamPatient issue (declined admission)
Problems with history
Problems ordering diagnostic test for further work-up in the ED
Patient with history of kidney stones and lithotripsy scheduled presented with new flank pain and dysuria. Nursing noted pain in right upper quadrant. Urinalysis with +leucocyte esterase, +RBCs, +WBCs, but no imaging was performed. Patient was discharged with antibiotics and urology follow-up, but returned a few days later with worsening pain. A diagnosis of cholecystitis with choledocholithiasis was madeProblems with history
Problems ordering diagnostic test for further work-up in the ED
  • ED, emergency department; PCP, primary care provider; RBC, red blood cells; WBC, white blood cells.