Diagnostic error: missed fractures in emergency medicine.

The following incident was submitted to the Emergency Medicine Events Register (EMER – http://www.emer .org.au). EMER is an anonymous, confidential and protected incidentreporting system that is supported by ACEM. Anyone working in emergency medicine can enter a near miss or AE by following the link from the website. It should only take 5 min and will help to inform practice and improve patient safety in emergency medicine. The case presented in Box 1 demonstrates the failure of an ED registrar to correctly identify a triquetral fracture on X-ray. A diagnostic error is broadly defined as any mistake or failure in the diagnostic process leading to a misdiagnosis, a missed diagnosis or a delayed diagnosis. Failure to diagnose a fracture accounts for up to 80% of ED diagnostic errors, occurs in 1% of all ED visits in a Norwegian hospital (when 3% of fractures were missed) and is a leading cause of litigation. The rate of missed fractures in emergency radiology is highest in the extremities (foot, 7.6%; hand, 5.4%; wrist, 4.1%; ankle, 2.8%), the knee (6.3%), elbow (6.0%) and hip (3.9%). This missed fracture highlights a system issue (lack of timely X-ray reporting) that could potentially result in significant patient harm. According to Reason (p. 768), a systems approach to error ‘concentrates on the conditions under which individuals work and tries to build defences to avert errors or mitigate their effects’. Such an approach is characteristic of high-reliability organisations, which proactively strive for comprehensive safety management targeting: the person, the team, the task, the workplace and the institution as a whole. There are numerous operating characteristics of the ED that contribute to errors, including the pace of the work, distractions and the lack of 24/7 access to other medical specialities, such as radiologists, to assist with diagnosis. X-ray interpretation by junior ED staff has high error rates. Missing fractures, even by radiologists, might occur as a result of ‘satisfaction of search’ – the reduced index of suspicion to search for more fractures once a fracture corresponding to the clinical findings has been identified. Guly suggested that fractures might be missed because incorrect radiographs were requested, highlighting the need for a thorough assessment and the need for ED doctors to specify the exact radiographic views that they require, and/or to state exactly the injury that they want to exclude. A lack of cooperation and communication between emergency and radiology departments is also a contributing factor to missed fractures. Additionally, it has been suggested that radiology trainees should have specific training in the interpretation of radio-