Tuesday, August 24th 2010

Contextual Error

er·ror
   /ˈɛrər/ Show Spelled[er-er] Show IPA
–noun
1. a deviation from accuracy or correctness; a mistake, as in action or speech: His speech contained several factual errors.
2. belief in something untrue; the holding of mistaken opinions.
3. the condition of believing what is not true: in error about the date.
4. a moral offense; wrongdoing; sin.

A mistake. That’s how I think of an error.

Here’s how we’re to think of contextual errors apparently,

A contextual error occurs when a physician overlooks elements of a patient’s environment or behavior that are essential to planning appropriate care. In contrast to biomedical errors, which are not patient-specific, contextual errors represent a failure to individualize care.

The above appears in a work by Weiner, et al in the Annals of Internal Medicine last month. I’m terribly poorly read on healthcare QA and medical errors but it appears to be a relatively novel concept. A search by title or keyword for “contextual error” in Medline reveals a total of three articles. The two other than Weiner’s have nothing to do with the idea as his group defines it.

I like the idea; I think it raises important considerations.

I don’t like the way Weiner’s group designed a study to document the prevalence of contextual errors.

Here is how a Huffington Post blog summarized the study from the Annals,

He sent undercover patients into doctor’s offices with regular complaints: a diabetic with blood sugar out of control. Raging asthma. Need for a hip replacement. They functioned as the “secret shoppers” of health care.)

In each case the actors could present a standard version of the problem, or versions where they offered a clue to an extra fact, something all physicians would agree should change the plan of care, if it were known. For the patient with raging asthma, one clue was “it’s been worse since I lost my job.”

A smart doctor would ask if new financial problems meant the patient could not pay for medicines. With that information in hand, the doctor could readily change to cheaper medications or identify a source of support. If a doctor fails to pick up on that clue, however, then they are likely to add new prescriptions. That would be the wrong decision.

Physicians only asked follow-up questions about those clues to good care about half the time. When there was a problem in the patient’s life situation, like inability to afford medicines, doctors only came up with an appropriate plan of care one time in five. Four times out of five, the patient left the office without receiving good care.

I’m not sure the example given represents a mistake on the part of the physician. Not in full. Not enough to claim,

That error rate is unacceptable.

Patient non-compliance with therapy is a failure of the medical system, but it is largely a patient side error. I’m not denying the responsibility of providers to promote social health and situations that facilitate patient compliance. But a patient who presents to a physician with worsening of his symptoms and doesn’t offer the fact that he’s been non-compliant with the recommended therapy because he can’t afford it, well, that is fully on the patient.

Telling physicians they’ve made a mistake for not ferreting out the complex situations in which patients aren’t compliant during a fifteen minute office visit is bollocks.

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