Frequency of Different Types of Diagnostic Errors in Patients with Central Nervous System Infections: A Cross-Sectional Observational Study
Table 2
Examples of diagnostic errors based on cognitive contributions to error.
Cases
Type of error
An 18-year-old girl was scheduled to sit her university entrance examinations in a couple of weeks while presented to the emergency department with acute onset of aggression and abnormal behavioral. The emergency physician diagnosed her as suffering from a hallucination disorder due to exam stress and—ignoring the patient’s high fever—referred the patient to a psychiatric hospital. It was ten days until they noticed her unusually high fever and referred her to the infectious diseases ward. The patient was diagnosed with herpetic encephalitis, but she was discharged from hospital with severe sequelae.
Premature closure of diagnosis
A 28-year-old, drug-addicted prisoner was taken to the prison medical clinic by his roommate because of loss of consciousness. The physician’s first probable diagnosis was narcotics abuse, and the young man was sent to the city hospital. The neurologist confirmed this diagnosis—without examining the patient—and referred him to a tertiary hospital, where he was hospitalized in the ICU. A post-mortem autopsy proved acute bacterial meningitis.
Premature closure of diagnosis
A 22-year-old boy visited his otolaryngologist with complaint of nasal watery discharge. The symptom began 3 days after nasal polyp removal. The doctor prescribed antihistamines for him. Two days later, he was referred again with severe headache and fever, but the doctor only prescribed cefixime and ibuprofen. The night after this visit, he was brought to the emergency department with agitation and high-grade fever. Lumbar puncture revealed bacterial meningitis and the patient died a few hours later.
Misjudging the salience of findings
A 63-year-old man with gastric lymphoma presented to an emergency unit with complaint of vomiting and severe headache. Frequent vomiting caused him heartburn and the clinical impression assumed to be an ischemic heart attack. But he was discharged because of normal ECGs and serum cardiac enzymes. The day after, he was brought to our emergency department with febrile encephalopathy. On examination, he had decreases level of consciousness and meningeal signs. Lumbar puncture revealed bacterial meningitis. He became intubated and after 21 days of admission in intensive care unit, he was discharged from hospital with severe sequelae.
Faulty perception
A 26-year-old girl was admitted to a hospital with complaint of fever and headache 3 weeks ago. The day after her labs were drawn, she was referred to a nephrology center because of severe hyponatremia. The cranial nerve palsies which were subtle at admission progressed and level of consciousness decreased during the following week. After 10 days a consultation with infectious diseases specialist was requested due to her continuous fever. On examination, she had stiff neck and positive Kernig’s sign. Brain CT scan showed hydrocephalus and chest X-ray illustrated a miliary pattern. She was transferred to infectious diseases ward with the diagnosis of tuberculous meningitis/disseminated tuberculosis, but she never recovered completely.
