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2019 HSR&D/QUERI National Conference Abstract

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1150 — Identifying Psychiatric Diagnostic Errors through Electronic Medical Record Reviews

Lead/Presenter: Terri Fletcher,  COIN - Houston
All Authors: Fletcher TL (Center for Innovation in Quality, Effectiveness, and Safety), Helm A (Center for Innovation in Quality, Effectiveness, and Safety, Houston), Vaghani V(Center for Innovation in Quality, Effectiveness, and Safety, Houston) Stanley MA(Center for Innovation in Quality, Effectiveness, and Safety, Houston) Kunik ME(Center for Innovation in Quality, Effectiveness, and Safety, Houston) Singh H(Center for Innovation in Quality, Effectiveness, and Safety, Houston)

Objectives:
Diagnostic errors in psychiatry are understudied and difficult to measure, particularly due to absence of objective diagnostic data such as labs and imaging. We adapted the Safer Dx Instrument, a structured tool to review electronic medical records for errors in medical diagnoses, to measure psychiatric diagnostic errors. Our specific aim was to adapt and test the Safer Dx Instrument to evaluate errors in anxiety diagnoses in a sample of Veterans diagnosed in primary care-mental health integration (PCMHI) settings as a first step to improve measurement of diagnostic errors in psychiatry. We focused on anxiety diagnostic error because unspecified anxiety disorder is the most common anxiety-related diagnosis in VA PCMHI settings but < 2% of Veterans diagnosed with unspecified anxiety actually meet diagnostic criteria for this disorder.

Methods:
We used an iterative process to adapt the Safer Dx Instrument questions, including a review by mental health providers to ensure content and face validity, review by a psychometrician to ensure methodologic validity, and pilot testing of the revised instrument on a sample of 128 records of patients diagnosed with anxiety in integrated primary care-mental health clinics. Cases in which anxiety diagnoses were documented in the progress notes but not included as a diagnosis for the encounter (n = 25) were excluded.

Results:
Of 103 records that met inclusion criteria, 62 were determined to involve a diagnostic error (42 errors due to use of unspecified anxiety diagnosis when a specific anxiety diagnosis was warranted; 20 errors due to use of unspecified anxiety diagnosis when anxiety symptoms were either not documented, or were documented but not severe enough to warrant diagnosis). Reviewer agreement on presence/absence of errors was 88% (? = 0.71).

Implications:
The revised ‘Safer Dx - Mental Health Instrument' has high reliability for detecting anxiety-related diagnostic errors. Future studies should test this instrument in additional psychiatric populations and clinical settings.

Impacts:
The provision of high-quality mental health care requires accurate, timely diagnosis. Identifying how, when, and under what circumstances psychiatric diagnostic errors occur is critical to improving the psychiatric diagnostic process and providing appropriate evidence-based mental health care.