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Overlooking Contextual Information in Medical Decision Making: A Source of Medical Error and Avoidable Cost

Weiner SJ, Schwartz A, Weaver FM, Goldberg J, Schapira MM, Yudkowsky R, Sharma G, Preyss B, Jordan N, Kaestner R. Overlooking Contextual Information in Medical Decision Making: A Source of Medical Error and Avoidable Cost. Presented at: VA HSR&D National Meeting; 2009 Feb 12; Baltimore, MD.


Objectives: A “contextual error” is a medical error that occurs when a physician fails to take into account information that is expressed outside of a patient’s physical boundaries – i.e. their context – that is essential to planning appropriate care. All other medical errors may be classified as “biomedical.” We are conducting a VA-funded study employing incognito standardized patients trained to present with either biomedical or contextual information that must be addressed by their physician in order to avoid a medical error. We examined the propensity of physicians to make both biomedical and contextual errors, and measured their avoidable direct costs to patient care. Methods: Using coding instruments developed for 4 cases, each with 4 variants, we scored 286 notes written by 96 internal medicine attending physicians who believed they were seeing new real patients in their primary care practice. To avoid making an error, a physician had to elicit and attend to essential biomedical or contextual information planted in each case. For each error identified, we tabulated each inappropriately ordered test, medication, or other medical service that was a direct consequence of the error and, using Medicare cost-based reimbursement data (which corresponds to VA Decision Support System costs) summed the overall costs of each error. Results: At least one error was made in 61% of cases where only a biomedical error was possible, 73% of cases where only a contextual error was possible, and 89% of case where physicians could make both types of errors. This trend was statistically significant (p = 0.05). Averaged across all 16 case variants, the cost of error-making to patient care was $326 in unnecessary or inappropriate care. For variants in which only contextual errors were possible, error-making added $725 to the per visit cost of care. Implications: Inattention to contextual information, such as patients’ transportation, economic situation, or caretaker responsibilities can be even more costly than inattention to laboratory values, medication dosages, and patient identifiers when delivering care. Impacts: This study suggests a need for greater prioritization of contextual information in planning patients’ care to reduce medical errors and costs.

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