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Contextual Errors

Michael A. LaCombe, MD
[+] Article, Author, and Disclosure Information

From MaineGeneral Medical Center, Augusta, Maine 04330

Potential Conflicts of Interest: None disclosed. Form can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M10-1268.

Corresponding Author: Michael A. LaCombe, MD, MaineGeneral Medical Center, 6 East Chestnut Street, Augusta, ME 04330; e-mail, mlacombe@mainegeneral.org.

Ann Intern Med. 2010;153(2):126-127. doi:10.7326/0003-4819-153-2-201007200-00009
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Some time ago at a national meeting, I was hung out to dry. On the spur of the moment, and appealing to my vanity, a course director (who shall be nameless until I get even with him) asked if I might show my legendary communication skills before a group by using a standardized patient. I would go first, show them how it was done, that sort of thing. Trapped by my ego, I was led to the slaughter—a hall of some 500 attendees watching on closed-circuit television—and handed an index card with my instructions. I was to meet the wife of my critical care unit patient in the family room and tell her that her husband was doing poorly and would not survive. I had barely delivered the bad news when this consummate actress leaned forward, grabbed my arms, and screamed, “But you promised! You told me you would save him! We have 3 small children, and you promised me you would save my husband!”

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Authors' Comments on Editorial
Posted on July 23, 2010
Saul J. Weiner
Jesse Brown VA Medical Center and University of Illinois at Chicago
Conflict of Interest: None Declared

We share Dr. LaCombe's perspective, in his editorial "Contextual Error" (1), on the value of the unannounced standardized patient assessment of physician practice, particularly for identifying contextual errors. We wish to clarify, however, exactly what we mean by a "contextual error" as some of his examples do not fit the criteria we have used in our research (2).

In a prior publication on the topic, where there was more room to elaborate, a contextual error was defined as occurring when there is "inattention to processes expressed outside of the boundaries of a patient's skin (i.e. that are a part of the context of a patient's illness)" (3). Hence, we would not regard missing the diagnosis of cocaine addiction in a patient presenting with unexplained weight loss and diaphoresis a contextual error. On the other hand, if the cocaine addiction were already known, and the presenting problem were poorly controlled diabetes, we would consider the addiction a part of the context of the patient's diabetes care. The failure to address the impact of addiction on medication adherence in such a situation -- and simply to keep increasing the dosage of the patient's insulin -- would constitute contextual error.

In the above example a biomedical problem (cocaine dependence) also becomes a contextual problem when it leads to behaviors that impact another illness. Typically, identifying contextual error is not so nuanced. LaCombe's examples of overlooking poor literacy or a patient's misunderstanding about how to correctly take their medication represent straightforward instances of contextual error.

In considering why contextual errors are so common, LaCombe postulates that "we are rushed; buffeted by multiple competing demands" and too often rely on clinical reflex, with little time to think." Interestingly, as reported in our paper, while we did find that when physicians had more time they were more likely to probe for biomedical and contextual red flags, we did not find that it was predictive of whether they would actually provide appropriate care. Within the time constraints they all faced, some physicians just performed better than others at synthesizing the information to avoid errors under similar circumstances, and when seeing identical (i.e. standardized) patients. The physicians who avoided errors seemed to be thinking differently, recognizing the relevance of a patient's context to planning appropriate care.


1. LaCombe MA. Contextual Error. Ann Intern Med. 2010;153:126-7.

2. Weiner SJ, Schwartz A, Weaver F, Goldberg J, Yudkowsky R, Sharma G, Binns-Calvey A, Preyss B, Schapira M, Persell SD, Jacobs E, Abrams R. Contextual errors and failures in individualizing patient care: A multicenter study. Ann Intern Med. 2010;153:69-75.

3. Weiner SJ. Contextual error. In: Kattan M, ed. Encyclopedia of Medical Decision Making. London: Sage; 2008:198-202.

Conflict of Interest:

None declared

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