Inadequacies of Physical Examination as a Cause of Medical Errors and Adverse Events: A Collection of Vignettes

doi:10.1016/j.amjmed.2015.06.004

The American Journal of Medicine

Volume 128, Issue 12, December 2015, Pages 1322-1324.e3

https://doi.org/10.1016/j.amjmed.2015.06.004 Get rights and content

Abstract

Background

Oversights in the physical examination are a type of medical error not easily studied by chart review. They may be a major contributor to missed or delayed diagnosis, unnecessary exposure to contrast and radiation, incorrect treatment, and other adverse consequences. Our purpose was to collect vignettes of physical examination oversights and to capture the diversity of their characteristics and consequences.

Methods

A cross-sectional study using an 11-question qualitative survey for physicians was distributed electronically, with data collected from February to June of 2011. The participants were all physicians responding to e-mail or social media invitations to complete the survey. There were no limitations on geography, specialty, or practice setting.

Results

Of the 208 reported vignettes that met inclusion criteria, the oversight was caused by a failure to perform the physical examination in 63%; 14% reported that the correct physical examination sign was elicited but misinterpreted, whereas 11% reported that the relevant sign was missed or not sought. Consequence of the physical examination inadequacy included missed or delayed diagnosis in 76% of cases, incorrect diagnosis in 27%, unnecessary treatment in 18%, no or delayed treatment in 42%, unnecessary diagnostic cost in 25%, unnecessary exposure to radiation or contrast in 17%, and complications caused by treatments in 4%. The mode of the number of physicians missing the finding was 2, but many oversights were missed by many physicians. Most oversights took up to 5 days to identify, but 66 took longer. Special attention and skill in examining the skin and its appendages, as well as the abdomen, groin, and genitourinary area could reduce the reported oversights by half.

Conclusions

Physical examination inadequacies are a preventable source of medical error, and adverse events are caused mostly by failure to perform the relevant examination.

Section snippets

Methods

We designed an 11-question, qualitative survey for physicians, who were asked to send us vignettes of known instances of oversights in physical examination and to answer related multiple choice questions. The study was approved by the Stanford University Institutional Review Board; the detailed instructions to the respondent and the questionnaire can be found online at www.surveymonkey.com/s/8S6DL7V.

A link to the questionnaire was sent to approximately 5000 physicians of diverse specialties

Results

Of the 263 responses received, 55 were excluded; of the 208 remaining responses, 27 were corrected by the criteria described in Methods.

Sixty-three percent of vignettes reported that the oversight was caused by a failure to perform the physical examination; 14% reported that the correct physical examination sign was elicited but misinterpreted. Eleven percent reported that the relevant sign was missed or not sought, and 12% reported “other” as the cause of the deficiency.

Consequence of the

Discussion

Recent publications describe the decline of physical examination skills.7, 8, 9, 10, 11, 12 Our study highlights the consequences and suggests that many adverse events are preventable. Our survey suggests that the major cause for error is simply that the examination is not performed.12, 13 In addition to diagnostic consequences, approximately half of the vignettes report treatment consequences. Most oversights pertained to a limited number of overlookers, suggesting that some errors may be

Acknowledgment

The authors thank Ralph Horwitz, MD, for his encouragement of the First Stanford Symposium on Bedside Medicine in 2009, and for his helpful discussions in planning this study.

References (13)

J.P. Kassirer et al.
Cognitive errors in diagnosis: instantiation, classification, and consequences
Am J Med
(1989)
C.A. Feddock
The lost art of clinical skills
Am J Med
(2007)
L.L. Willett et al.
Does residency training improve performance of physical examination skills?
Am J Med Sci
(2007)
K.T. Kohn et al.
To Err Is Human: Building a Safer Health System
(1999)
M.L. Graber et al.
Diagnostic error in internal medicine
Arch Intern Med
(2005)
H. Singh et al.
System-related interventions to reduce diagnostic errors: a narrative review
BMJ Qual Saf
(2012)

There are more references available in the full text version of this article.

Cited by (151)

Why is Turkey losing its doctors? A cross-sectional study on the primary complaints of Turkish doctors
2023, Heliyon
In 2022, Turkey encountered the formidable task of addressing an unprecedented loss of medical doctors and seeking remedies for potential issues within the healthcare system. This study set out to explore the inclination of 402 actively practicing Turkish doctors to depart from Turkey, assess the socio-demographic and socio-economic factors influencing this trend, and establish the hierarchy of raised concerns among doctors. Employing a cross-sectional and analytical approach, the study drew comparisons between doctors' demographic characteristics and the significance of their grievances, while also examining the correlation between the importance of complaints and the desire to remain in Turkey. The doctors' primary complaints encompassed financial challenges, instances of violence in the healthcare sector, and insufficient examination durations. The migration of doctors poses a substantial risk to healthcare accessibility, public health, and the sustainability of Turkey's healthcare delivery capacity. To mitigate this risk and curb doctor migration, corrective measures must be implemented to improve working conditions. Additionally, there is a need for further scientific research focusing on doctors' concerns, particularly in developing countries like Turkey, to expand the current body of literature on this subject.
Demise of the USMLE Step-2 CS exam: Rationalizing a way forward
2023, Journal of the National Medical Association
The COVID-19 pandemic has compelled rethinking and changes in medical education, the most controversial perhaps being the cancelation of USMLE Step-2 Clinical Skills exam (Step-2 CS). What started in March of 2020 as suspension of this professional licensure exam, because of concerns about infection risk for examinees, standardized patients (SPs), and administrators, soon became permanent cancelation in January 2021. Expectedly, it triggered debate in medical education circles. Positively, however, the USMLE regulatory agencies (NBME and FSMB) saw an opportunity to innovate an exam tainted with perceptions of validity deficits, cost, examinee inconvenience, and worries about future pandemics; they therefore called for a public debate to fashion a way forward. We have approached the issue by defining Clinical Skills (CS), exploring its epistemology and historic evolution, including assessment modalities from Hippocratic times to the modern era. We defined CS as the art of medicine manifest in the physician-patient encounter as history taking (driven by communication skills and cultural competence) and physical examination. We classified CS components into knowledge and psychomotor skill domains, established their relative importance in the physician process (clinical reasoning) of diagnosis, thus establishing a theoretical framework for developing valid, reliable, feasible, fair, and verifiable CS assessment. Given the concerns for COVID-19 and future pandemics, we established that CS can largely be assessed remotely, and what could not, can be assessed locally (school/regional consortia level) as part of a USMLE-regulated/supervised assessment regimen with established national standards, thus maintaining USMLE's fiduciary responsibilities. We have suggested a national/regional program for faculty development in CS curriculum development, and assessment, including standard setting skills. This pool of expert faculty will form the nucleus of our proposed USMLE-regulated External Peer Review Initiative (EPRI). Finally, we suggest that CS evolves into an academic discipline/department of its own, rooted in scholarship.
Orientation and mobility control of 4HCB organic film for flexible X-ray detectors with high performance
2023, Journal of Materials Science and Technology
Citation Excerpt :
Metal oxide and inorganic semiconductor devices (such as silicon) can approximate the dose at the site of irradiated, but, these devices can be invasive when rely on implanted in the patient's body [10]. Also the most high-Z detector are rigid, and these detectors can cause vignetting problems [11]. Unlike conventional solid state X-ray detectors, the mechanical flexibility and intrinsic compatibility of OSC detectors with flexible substrates allow them to be processed into large-area pixelated detector matrixes, and possibly onto curved objects or imaged in a tight space [12].
In comparison to inorganic counterparts, organic semiconducting (OSC) crystalline films are promising for building large-area and flexible ionizing radiation detectors for X-ray imaging or dosimetry due to their tissue equivalence, simple processing and large-scale production accessibility. Fabrication processes, however, hinder the ability to generate aligned and large-area films with high carrier mobility. In this work, the space-confined melt process is used to produce highly orientated 4HCB (4-hydroxycyanobenzene) OSC films with a large area of 15 × 18 mm². The out-of-plane direction of the 4HCB film is <001>, and the benzene rings are found to be extensively overlapped inside the in-plane direction, according to the XRD patterns. The film exhibits a high resistivity up to 10¹² Ω cm, and high hole mobility of 10.62 cm² V⁻¹ s⁻¹. Furthermore, the 4HCB (80 μm-thick film) based X-ray detectors can achieve a sensitivity of 93 μC Gy_air⁻¹ cm⁻² and on/off ratio of 157. The device also shows steady flexibility, with no degradation in detecting function after 100 cycles of bending. Finally, the proposed 4HCB film detectors demonstrated a high-resolution X-ray imaging capability. The imaging of several materials with sharp edges (copper and polytetrafluoroethylene) has been obtained. This work has developed a fast but efficient approach for producing large-area, highly oriented OSC films for high-performance X-ray detectors.
All-Inorganic Ruddlesden-Popper Perovskite Cs<inf>2</inf>CdCl<inf>4</inf>:Mn for Low-Dose and Flexible X-ray Imaging
2024, ACS Materials Letters
The role of VR with haptic feedback in enhancing physical examination skills of health care students: a systematic review
2024, Research Square
Too much versus too little: looking for the “sweet spot” in optimal use of diagnostic investigations
2024, Medical Journal of Australia

View all citing articles on Scopus

: Funding: None.

: Conflict of Interest: None.

: Authorship: All authors had access to the data and a role in writing the manuscript.

View full text

Clinical research studyInadequacies of Physical Examination as a Cause of Medical Errors and Adverse Events: A Collection of Vignettes

Abstract

Background

Methods

Results

Conclusions

Section snippets

Methods

Results

Discussion

Acknowledgment

Am J Med

Am J Med

Am J Med Sci

To Err Is Human: Building a Safer Health System

Diagnostic error in internal medicine

Arch Intern Med

System-related interventions to reduce diagnostic errors: a narrative review

BMJ Qual Saf

Clinical research study
Inadequacies of Physical Examination as a Cause of Medical Errors and Adverse Events: A Collection of Vignettes