Clinical question: What is the frequency of diagnostic delays in epidural abscesses, and what factors may contribute to these delays?
Background: Diagnostic evaluation of back pain can be challenging. Missed diagnosis of serious conditions such as epidural abscesses can lead to significant morbidity.
Study design: Retrospective chart review.
Setting: Veterans Affairs Electronic Medical Record database from more than 1,700 VA outpatient and inpatient facilities in the United States.
Synopsis: Of the 119 patients with a new diagnosis of spinal epidural abscess, 55.5% were felt to have experienced a diagnostic error, defined by the study authors as a missed opportunity to evaluate a red flag (e.g. weight loss, neurologic deficit, fever) in a timely or appropriate manner. There was a significant difference in the time to diagnosis between patients with and without a diagnostic error (4 versus 12 days, P less than .01). Of those cases involving diagnostic error, 60.6% were felt to have resulted in serious patient harm and 12.1% in patient death. The most commonly missed red flags were fever, focal neurological deficits, and signs of active infection.
Based on these findings, the authors suggest that future intervention focus on improving information gathering during patient-physician encounter and physician education about existing guidelines.
The limitations of this study include its use of data from a single health system, and the employment of chart reviews instead of a root cause analysis based on provider and patient interviews.
Bottom line: A delay in diagnosis resulting in patient harm or death may occur frequently in cases of epidural abscesses. Further work on targeted interventions to reduce error and prevent harm are needed.
Citation: Bhise V, Meyer A, Singh H, et al. Diagnosis of spinal epidural abscesses in the era of electronic health records. Am J Med. 2017;130(8):975-81.
Dr. Pizza is a hospitalist, Beth Israel Deaconess Medical Center, and instructor in medicine, Harvard Medical School, Boston.