Saul J. Weiner, MD; Alan Schwartz, PhD; Frances Weaver, PhD; Julie Goldberg, PhD; Rachel Yudkowsky, MD, MHPE; Gunjan Sharma, PhD; Amy Binns-Calvey; Ben Preyss, BA; Marilyn M. Schapira, MD, MPH; Stephen D. Persell, MD, MPH; Elizabeth Jacobs, MD, MPP; Richard I. Abrams, MD
Disclaimer: The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the U.S. Department of Veterans Affairs or the U.S. government.
Acknowledgment: The authors thank Simon Auster, MD, JD, Uniformed Services University of the Health Sciences, and Michael Berbaum, PhD, University of Illinois at Chicago, for their constructive input, particularly during the planning and analysis stages of the study.
Grant Support: By the Department of Veterans Affairs Health Services Research and Development Service (grant IIR 04-107).
Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M10-0665.
Reproducible Research Statement:Study protocol and statistical code: Available at www.cmc3.research.va.gov. Data set: Not available.
Requests for Single Reprints: Saul J. Weiner, MD, University of Illinois at Chicago, Academic and Educational Affairs, College of Medicine, 1853 West Polk Street, CMW 105, Chicago, IL 60612-7324; e-mail, firstname.lastname@example.org.
Current Author Addresses: Dr. Weiner: Jesse Brown Veterans Affairs Medical Center, Medical Service, Department of Veterans Affairs, and University of Illinois at Chicago, Academic and Educational Affairs, College of Medicine, 1853 West Polk Street, CMW 105, Chicago, IL 60612-7324.
Drs. Schwartz, Goldberg, and Yudkowsky and Ms. Binns-Calvey: Department of Medical Education, MC 591, University of Illinois at Chicago College of Medicine, 808 South Wood Street, Chicago, IL 60612.
Dr. Weaver: Center for Management of Complex Chronic Care, 151H, Building 1, Room B260, 5000 South 5th Avenue, Hines Veterans Affairs Hospital, Hines, IL 60141.
Dr. Sharma: Jesse Brown Veterans Affairs Medical Center, Building 11A, MC 151, 820 South Damen Avenue, Chicago, IL 60612.
Mr. Preyss: 1502 West Ohio Street, 2F, Chicago, IL 60642.
Dr. Schapira: Center for Patient Care and Outcomes Research, 8701 Watertown Plank Road, Milwaukee, WI 53226.
Dr. Persell: Division of General Internal Medicine, Feinberg School of Medicine, Institute for Healthcare Studies, Northwestern University, 750 North Lake Shore Drive, 10th Floor, Chicago, IL 60611.
Dr. Jacobs: Collaborative Research Unit, John H. Stroger, Jr. Hospital of Cook County and Rush University Medical Center, 1900 West Polk Street, Chicago, IL 60612.
Dr. Abrams: Rush University Medical Center, Department of Medicine, Room 301 Jones, 1653 West Congress Parkway, Chicago, IL 60612.
Author Contributions: Conception and design: S.J. Weiner, A. Schwartz, F. Weaver, J. Goldberg.
Analysis and interpretation of the data: S.J. Weiner, A. Schwartz, M.M. Schapira.
Drafting of the article: S.J. Weiner, A. Schwartz, M.M. Schapira.
Critical revision of the article for important intellectual content: S.J. Weiner, A. Schwartz, J. Goldberg, R. Yudkowsky, M.M. Schapira, S.D. Persell, E. Jacobs.
Final approval of the article: S.J. Weiner, A. Schwartz, F. Weaver, J. Goldberg, R. Yudkowsky, M.M. Schapira, S.D. Persell, E. Jacobs, R. Abrams.
Provision of study materials or patients: S.J. Weiner, M.M. Schapira, S.D. Persell, E. Jacobs, R. Abrams.
Statistical expertise: A. Schwartz.
Obtaining of funding: S.J. Weiner, F. Weaver, J. Goldberg.
Administrative, technical, or logistic support: S.J. Weiner, F. Weaver, J. Goldberg, G. Sharma, A. Binns-Calvey, M.M. Schapira, E. Jacobs, R. Abrams.
Collection and assembly of data: S.J. Weiner, J. Goldberg, R. Yudkowsky, G. Sharma, A. Binns-Calvey, M.M. Schapira, S.D. Persell, E. Jacobs.
Weiner SJ, Schwartz A, Weaver F, Goldberg J, Yudkowsky R, Sharma G, et al. Contextual Errors and Failures in Individualizing Patient Care: A Multicenter Study. Ann Intern Med. 2010;153:69-75. doi: 10.7326/0003-4819-153-2-201007200-00002
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Published: Ann Intern Med. 2010;153(2):69-75.
This article has been corrected. For original version, click â€œOriginal Version (PDF)â€ in column 2.
A contextual error occurs when a physician overlooks elements of a patient's environment or behavior that are essential to planning appropriate care. In contrast to biomedical errors, which are not patient-specific, contextual errors represent a failure to individualize care.
To explore the frequency and circumstances under which physicians probe contextual and biomedical red flags and avoid treatment error by incorporating what they learn from these probes.
An incomplete randomized block design in which unannounced, standardized patients visited 111 internal medicine attending physicians between April 2007 and April 2009 and presented variants of 4 scenarios. In all scenarios, patients presented both a contextual and a biomedical red flag. Responses to probing about flags varied in whether they revealed an underlying complicating biomedical or contextual factor (or both) that would lead to errors in management if overlooked.
14 practices, including 2 academic clinics, 2 community-based primary care networks with multiple sites, a core safety net provider, and 3 U.S. Department of Veterans Affairs facilities.
Primary outcomes were the proportion of visits in which physicians probed for contextual and biomedical factors in response to hints or red flags and the proportion of visits that resulted in error-free treatment plans.
Physicians probed fewer contextual red flags (51%) than biomedical red flags (63%). Probing for contextual or biomedical information in response to red flags was usually necessary but not sufficient for an error-free plan of care. Physicians provided error-free care in 73% of the uncomplicated encounters, 38% of the biomedically complicated encounters, 22% of the contextually complicated encounters, and 9% of the combined biomedically and contextually complicated encounters.
Only 4 case scenarios were used. The study assessed physicians' propensity to make errors when every encounter provided an opportunity to do so and did not measure actual error rates that occur in primary care settings because of inattention to context.
Inattention to contextual information, such as a patient's transportation needs, economic situation, or caretaker responsibilities, can lead to contextual error, which is not currently measured in assessments of physician performance.
U.S. Department of Veterans Affairs Health Services Research and Development Service.
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