Contextual Errors and Failures in Individualizing Patient Care
Abstract
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 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. 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 provided 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 patient's transportation needs, economic situation, or caretaker responsibilities, 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
Integrity signals
Registry
Cites
Statistics
Claims the paper makes
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
Clinicians address contextual factors 60% to 70% of the time.
“Clinicians address them 60% to 70% of the time, leaving substantial room for improvement.6,7”
From Effect of Electronic Health Record Clinical Decision Support on Contextualization of Care (2022) · cites this paper as [7]
Cites
Evidence based medicine: what it is and what it isn't
Sackett, D. L., Rosenberg, W. M. C., Gray, J. A. M., Haynes, R. B., & Richardson, W. S. (1996) · BMJ · doi:10.1136/bmj.312.7023.71 · Cited by 15,769 · see citing works
Institute of Medicine (2000) · National Academies Press eBooks · doi:10.17226/9728 · Cited by 14,174 · see citing works
Applied Mixed Models in Medicine
Brown, H., & Presco, R. (2000) · Technometrics · doi:10.1080/00401706.2000.10485742 · Cited by 1,699 · see citing works
The prevalence of limited health literacy
Paasche‐Orlow, M. K., Parker, R. M., Gazmararian, J. A., Nielsen-Bohlman, L., & Rudd, R. R. (2005) · Journal of General Internal Medicine · doi:10.1111/j.1525-1497.2005.40245.x · Cited by 1,387 · see citing works
Juniper, E. F., Bousquet, J., Abetz, L. N., & Bateman, E. D. (2005) · Respiratory Medicine · doi:10.1016/j.rmed.2005.08.012 · Cited by 998 · see citing works
The Economic Value Of Informal Caregiving
Arno, P. S., Levine, C., & Memmott, M. M. (1999) · Health Affairs · doi:10.1377/hlthaff.18.2.182 · Cited by 680 · see citing works
Howell, D. C. (2007) · SAGE Publications Ltd eBooks · doi:10.4135/9781848607958.n11 · Cited by 280 · see citing works
Breslin, M., Mullan, R. J., & Montori, V. M. (2008) · Patient Education and Counseling · doi:10.1016/j.pec.2008.07.024 · Cited by 155 · see citing works
Hunger in an Adult Patient Population
Nelson, K. N. (1998) · JAMA · doi:10.1001/jama.279.15.1211 · Cited by 141 · see citing works
Contextualizing medical decisions to individualize care
Weiner, S. J. (2004) · Journal of General Internal Medicine · doi:10.1111/j.1525-1497.2004.30261.x · Cited by 125 · see citing works
Self-citationStange, K. C. (2009) · The Annals of Family Medicine · doi:10.1370/afm.990 · Cited by 78 · see citing works
Primary Care Quality and Addiction Severity: A Prospective Cohort Study
Kim, T. W., Samet, J. H., Cheng, D. M., Winter, M. R., Safran, D. G., & Saitz, R. (2006) · Health Services Research · doi:10.1111/j.1475-6773.2006.00630.x · Cited by 53 · see citing works
Weiner, S. J., Schwartz, A., Yudkowsky, R., et al. (2007) · Medical Decision Making · doi:10.1177/0272989x07306113 · Cited by 38 · see citing works
Self-citationFranz, C. E., Epstein, R. M., Miller, K., et al. (2006) · Health Services Research · doi:10.1111/j.1475-6773.2006.00560.x · Cited by 37 · see citing works
From research evidence to context: The challenge of individualizing care
Saul J. Weiner, M. (2004) · ACP Journal Club · doi:10.7326/acpjc-2004-141-3-a11 · Cited by 36 · see citing works
A conditional model of evidence‐based decision making
Falzer, P. R., & Garman, M. D. (2009) · Journal of Evaluation in Clinical Practice · doi:10.1111/j.1365-2753.2009.01315.x · Cited by 25 · see citing works
Falzer, P. R., & Garman, D. M. (2010) · Academic Medicine · doi:10.1097/acm.0b013e3181ccd83c · Cited by 19 · see citing works
Flagged first, then by citations
Cited by
Sorted by citations
A New, Evidence-based Estimate of Patient Harms Associated with Hospital Care
James, J. T. (2013) · Journal of Patient Safety · doi:10.1097/pts.0b013e3182948a69 · Cited by 1,399 · see citing works
Bayliss, E. A., Bonds, D. E., Boyd, C. M., Davis, M. M., Finke, B., Fox, M. H., Glasgow, R. E., Goodman, R. A., Heurtin-Roberts, S., Lachenmayr, S., et al. (2014) · The Annals of Family Medicine · doi:10.1370/afm.1643 · Cited by 225 · see citing works
Sayer, N. A., Frazier, P., Orazem, R. J., Murdoch, M., Gravely, A., Carlson, K. F., Hintz, S., & Noorbaloochi, S. (2011) · Journal of Traumatic Stress · doi:10.1002/jts.20706 · Cited by 180 · see citing works
Cook, D. A., Overgaard, J., Pankratz, V. S., Del Fiol, G., & Aakre, C. A. (2025) · Journal of Medical Internet Research · doi:10.2196/68486 · Cited by 96 · see citing works
Weiner, S., Schwartz, A., Altman, L., Ball, S., Bartle, B., Binns-Calvey, A., Chan, C., Falck-Ytter, C., Frenchman, M., Gee, B., et al. (2020) · JAMA Network Open · doi:10.1001/jamanetworkopen.2020.9644 · Cited by 60 · see citing works
Self-citationPatient-collected audio for performance assessment of the clinical encounter
Weiner, S. J., Schwartz, A., Sharma, G., Binns-Calvey, A., Ashley, N., Kelly, B., & Weaver, F. M. (2015) · The Joint Commission Journal on Quality and Patient Safety · doi:10.1016/s1553-7250(15)41037-2 · Cited by 27 · see citing works
Self-citationEffect of Electronic Health Record Clinical Decision Support on Contextualization of Care
Weiner, S. J., Schwartz, A., Weaver, F., Galanter, W., Olender, S., Kochendorfer, K., Binns-Calvey, A., Saini, R., Iqbal, S., Diaz, M., et al. (2022) · JAMA Network Open · doi:10.1001/jamanetworkopen.2022.38231 · Cited by 26 · see citing works
Self-citation
- Authors
- Weiner, S. J., Schwartz, A., Weaver, F., Goldberg, J., Yudkowsky, R., Sharma, G., Binns-Calvey, A., Preyss, B., M. Schapira, M., Persell, S. D., Jacobs, E., & Abrams, R. I.
- Affiliations
- Northwestern University (US)
- From Veterans Affairs Center for the Management of Complex Chronic Care, University of Illinois at Chicago, Jesse Brown Veterans Affairs Medical Center, Feinberg School of Medicine, Northwestern University, John H. Stroger, Jr. Hospital, and Rush University Medical Center, Chicago, Illinois; Edward Hines Veterans Affairs Medical Center, Hines, Illinois; and Clement J. Zablocki Veterans Affairs Medical Center and Medical College of Wisconsin, Milwaukee, Wisconsin.
- ORCID
- Venue
- Annals of Internal Medicine
- Publisher
- American College of Physicians
- Published
- 2010-07-20
- Volume
- 153
- Issue
- 2
- Pages
- 69-75
- ISSN
- 0003-4819 (ISSN-L)
- 1539-3704
- OpenAlex
- W2129404566
- Semantic Scholar
- 275f6f951ca193f329bafadc8a79d1c25aeccf44
- Cited by
- 214
- References
- 17
- Citations by year
- 2026: 4 · 2025: 15 · 2024: 8 · 2023: 11 · 2022: 9 · 2021: 20 · 2020: 11 · 2019: 11 · 2018: 10 · 2017: 11 · 2016: 14 · 2015: 29 · 2014: 14 · 2013: 16 · 2012: 16
- FWCI
- 13.01
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Annals of Internal Medicine (publishedVersion)
- PubMed (publishedVersion)
- Annals of Internal Medicine
- Topics
- Health Sciences › Medicine › Family Practice › Clinical Reasoning and Diagnostic Skills
- Health Sciences › Health Professions › Emergency Medical Services › Patient Safety and Medication Errors
- Health Sciences › Health Professions › General Health Professions › Primary Care and Health Outcomes
- Keywords
- contextual errors, individualized care, red flags, treatment errors, patient context, socioeconomic factors, transportation needs, primary care, patient safety, physician performance assessment
- MeSH terms
- Adult, Aged, Decision Making, Female, Humans, Internal Medicine, Male, Medical History Taking, Middle Aged, Outcome and Process Assessment, Health Care, Logistic Models, Patient Simulation, Patient-Centered Care, Medical Errors
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
Are you an author, or do you see a problem with this page? Request a review
