Contextual Medical Errors

A recent article in the Annals of internal Medicine by Saul Weiner, et al, titled "Contextual Errors and Failures in Individualizing Patient Care" was at once amazing to me but also, at the same time, not that surprising.

The amazing part actually occurred on several levels.

The first is that only 73% of experienced physicians when presented with an uncomplicated standardized patient handled the encounter without error. It seems like we should have done better.

The second thing is that, in more complicated biomedical situations, only 38% got it right.

The third and most amazing point is that when the encounter was medically straightforward but complicated by contextual issues (non-medical problems that prevent the patient from receiving proper healthcare – things like illiteracy, inability to afford prescriptions, etc.), those types of problems were explored and dealt with appropriately only 22% of the time.

Even worse was the 91% failure rate of physicians being able to deal with patients who had both medical and contextual complications. These types of patients unfortunately make up a significant portion of most physicians’ office practices.

Why are these figures so bad? Is it because our knowledge is lacking? Considering the knowledge base of most physicians that I know, I doubt that is the case. Is it because we don’t care? That’s not the case either. We all work hard in this business because we do care.

I suspect the biggest problem is the time factor. Dr. Michael LaCombe, in the accompanying editorial, agreed, writing, “We are rushed; buffeted by multiple, often conflicting demands...and too often rely on clinical reflex, with little time left to think - and thinking is vital to avoiding contextual error.”

None of us in busy office practices, seeing 4 patients every hour, dealing with urgent phone calls and paperwork and keeping our patient records up to date, have much time to delve into anything more than straightforward or uncomplicated issues. Nor do we have time to think about whether one of our patients can afford to take the medication prescribed. We may figure that it’s our job to do the medical thing and society’s job to do the rest. Meanwhile, our patients are still not getting healthier, even if they are seeing the smartest doc in the city.

There is a disconnect there that we should be mindful of and try to explore and correct whenever possible. We have to actively think about this when we are seeing our patients. We have to remember to individualize care. Find out what their lives are like, what kind of family support they have, whether they have insurance, whether they can read their prescription label, etc. That’s part of the visit, not just the blood pressure or the blood sugar.

Unfortunately, however, we often don’t have time for this. When you’re 30-60minutes behind and the patients in the waiting room are restless, all you can think about is getting done with this patient so you can move on to the next.

Nevertheless, we have to do the best we can with it - to prevent the contextual medical errors as well as the biomedical errors (both of which are regarded as medical errors by the Institute of Medicine). Perhaps our nurses could be trained to explore some of these questions before each visit as they are doing the vitals. Perhaps, implementing the medical-home concept will help, although practically speaking, it seems rather difficult to apply in real life. Perhaps the increase in retainer-based medicine rather than the current fee-for-visit model would help.

Anyway, the point to be made is that we should try to always keep in mind that our patients are people with other problems like poverty, stress, family issues or lack thereof in some cases, not just diseases. Sometimes their diseases won’t get better if we don’t address the other problems.

References on Contextual Medical Errors:

Weiner, Saul, et al, "Contextual Errors and Failure in Individualizing Patient Care", Annals of Internal Medicine, July 20, 2010, 153:2, pp69-75.

Lacombe, Michael, "Contextual Errors", Annals of Internal Medicine, July 20, 2010, 153:2, pp126-7.

This page was last updated on August 8, 2010.

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