Contextual Errors and Failures in Individualizing Patient Care A Multicenter Study 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; and Richard I. Abrams, MD Background: 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. Objective: 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. Design: An incomplete randomized block design in which unan- nounced, standardized patients visited 111 internal medicine at- tending physicians between April 2007 and April 2009 and pre- sented 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 compli- cating biomedical or contextual factor (or both) that would lead to errors in management if overlooked. Setting: 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. Measurements: 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. Results: 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. Limitations: Only 4 case scenarios were used. The study assessed physicians’ propensity to make errors when every encounter pro- vided an opportunity to do so and did not measure actual error rates that occur in primary care settings because of inattention to context. Conclusion: Inattention to contextual information, such as a pa- tient’s transportation needs, economic situation, or caretaker re- sponsibilities, can lead to contextual error, which is not currently measured in assessments of physician performance. Primary Funding Source: U.S. Department of Veterans Affairs Health Services Research and Development Service. Ann Intern Med. 2010;153:69-75. www.annals.org For author affiliations, see end of text. C linical decision making has been described (1) as an- swering the question, “What is the best next thing for this patient at this time?” To be effective and safe, care plans must be tailored to a patient’s individual circum- stances. Intensifying the medication regimen for a patient with poorly controlled asthma who cannot afford his or her current medications is an example of ordinarily appropriate provider behavior that represents inappropriate care under the circumstances. According to the Institute of Medicine (2), an inap- propriate plan of care is a medical error. We refer to decision-making errors that occur because of inattention to patient context as contextual errors (1, 3). By patient con- text, we mean those elements of a patient’s environment or behavior that are relevant to their care, including their eco- nomic situation, access to care, social support, and skills and abilities. Contextual errors represent a failure to indi- vidualize care (4). All other decision-making errors may be classified as biomedical errors (3). Decision-making errors can occur if clinicians do not identify clinically essential information or do not correctly incorporate essential information into the plan of care. In a previous study (5), we developed and tested a method for assessing physician propensity to make contextual or biomedical errors in clinical encounters with standardized patients. In this study, we applied that method in a multicenter field experiment by using unannounced, standardized patients to assess how well-experienced inter- nal medicine physicians can probe for contextual and bio- medical factors in response to hints (red flags) and incor- porate their findings into the plan of care. See also: Print Editors’ Notes .............................. 70 Editorial comment.......................... 126 Web-Only Appendix Table Video supplement Conversion of graphics into slides This article has been corrected. The specific correction appears on the last page of this document. For original version, click Original Version (PDF) in column 2 of the article at www.annals.org. Annals of Internal Medicine Article © 2010 American College of Physicians 69 Downloaded From: http://annals.org/ by a Duke Medical Library User on 04/19/2013