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Last Updated: May 9, 2024
Created By: Karen Cosby, AHRQ
Description
This curated library highlights the prevalence and consequences of diagnostic errors in healthcare settings. It includes articles showcasing how diagnostic errors lead to malpractice claims, with significant financial costs and severe outcomes, and also contains items emphasizing the need for comprehensive review and improvement strategies.
Library Organization
Custom - This library is organized by custom section header names.
Incidence of Diagnostic Errors (7)
Tehrani ASS, Lee HW, Mathews SC, et al. BMJ Qual Saf. 2013;22:672-680.
The patient safety consequences of diagnostic errors have been receiving greater attention in the past few years, after... Read More
Gupta A, Snyder A, Kachalia A, et al. BMJ Qual Saf. 2017;27:53-60.
Characterization of diagnostic error in the hospital setting has traditionally relied on data from autopsy studies, but the continuing decline in autopsy rates necessitates... Read More
Grenon V, Szymonifka J, Adler-Milstein J, et al. J Patient Saf. 2023;19:211-215.
Large malpractice claims databases are increasingly used as a proxy to assess the frequency and severity of diagnostic errors. More than 5,300 closed claims... Read More
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Measurement of Diagnostic Error (2)
Leape L, Brennan TA, Laird N, et al. N Engl J Med. 1991;324:377-84.
The authors analyzed the nature of injuries sustained in a cohort of hospitalized patients in New York in 1984. Physician reviewers evaluated... Read More
Wachter RM. Health Aff (Millwood). 2010;29:1605-1610.
This commentary discusses the challenges in measuring diagnostic errors and developing solutions for prevention. The author discusses the potential roles of health... Read More
Patient Engagement in Diagnosis (3)
Sacco AY, Self QR, Worswick EL, et al. J Patient Saf. 2021;17:e1759-e1773.
Using the IOM definition of diagnostic error, this study interviewed hospitalized adults to characterize their experiences with diagnostic errors and their perspectives on causes,... Read More
Dukhanin V, McDonald KM, Gonzalez N, et al. Med Decis Making. 2024;44:102-111.
Patient engagement and shared decision-making are important components of diagnostic excellence. This study sought to understand if patients with... Read More
McDonald KM, Bryce CL, Graber ML. BMJ Qual Saf. 2013;22 Suppl 2:ii33-ii39.
Diagnostic errors are increasingly recognized as an important—and costly—aspect of patient safety. This study advocates for engaging patients to improve diagnostic... Read More
Uncertainty in Diagnosis (3)
Kassirer JP. N Engl J Med. 1989;320:1489-1491.
The topic of uncertainty has been largely neglected in the literature despite an understanding that diagnostic reasoning is largely probabilistic. This commentary acknowledges how uncertainty drives... Read More
Meyer AND, Giardina TD, Khawaja L, et al. Patient Educ Couns. 2021;104:2606-2615.
Diagnostic uncertainty can lead to misdiagnosis and delayed treatment. This article provides an overview of the literature on... Read More
JAMA. Nov 2021-Sep 2022.
Diagnostic excellence achievement is becoming a primary focus in health care. This 20-article series covers diagnosis as it relates to the Institute of Medicine quality domains, clinical challenges and uncertainties, and... Read More
Economics and Cost of Diagnosis (1)
Newman-Toker DE, McDonald KM, Meltzer DO. BMJ Qual Saf. 2013;22:ii11-ii20.
This commentary uses case examples to demonstrate how economic analysis may help inform efforts to improve the safety of diagnostic decision making.
All Library Content (16)
Commentary
Kassirer JP. N Engl J Med. 1989;320(22):1489-1491.
The topic of uncertainty has been largely neglected in the literature despite an understanding that diagnostic reasoning is largely probabilistic. This commentary acknowledges how uncertainty drives reasoning, test overuse, and physician discomfort to culminate in waste and reduced quality.
Dukhanin V, McDonald KM, Gonzalez N, et al. Med Decis Making. 2024;44(1):102-111.
Patient engagement and shared decision-making are important components of diagnostic excellence. This study sought to understand if patients with emergency department visits in the previous 30 days agreed or disagreed with their diagnosis and their reasoning process. Understanding patients' reasoning regarding the accuracy of their diagnosis can inform clinical practice and research.
Grenon V, Szymonifka J, Adler-Milstein J, et al. J Patient Saf. 2023;19(3):211-215.
Large malpractice claims databases are increasingly used as a proxy to assess the frequency and severity of diagnostic errors. More than 5,300 closed claims with at least one diagnostic error were analyzed. No singular factor was identified; instead multiple contributing factors were implicated along the diagnostic pathway.
Special or Theme Issue
JAMA. Nov 2021-Sep 2022.
Diagnostic excellence achievement is becoming a primary focus in health care. This 20-article series covers diagnosis as it relates to the Institute of Medicine quality domains, clinical challenges and uncertainties, and priorities for improvement across the system.
Meyer AND, Giardina TD, Khawaja L, et al. Patient Educ Couns. 2021;104(11):2606-2615.
Diagnostic uncertainty can lead to misdiagnosis and delayed treatment. This article provides an overview of the literature on diagnosis-related uncertainty, where uncertainty occurs in the diagnostic process and outlines recommendations for managing diagnostic uncertainty.
Raffel KE, Kantor MA, Barish P, et al. BMJ Qual Saf. 2020;29(12):971-979.
This retrospective cohort study characterized diagnostic errors among adult patients readmitted to the hospital within 7 days of hospital discharge. Over a 12-month period, 5.6% of readmissions were found to contain at least one diagnostic error during the index admissions. These diagnostic errors were primarily related to clinician diagnostic reasoning, including failure to order needed tests, erroneous interpretation of tests, and failure to consider the correct diagnosis. The majority of the diagnostic errors resulted in some form of clinical impact, including short-term morbidity and readmissions.
Sacco AY, Self QR, Worswick EL, et al. J Patient Saf. 2021;17(8):e1759-e1773.
Using the IOM definition of diagnostic error, this study interviewed hospitalized adults to characterize their experiences with diagnostic errors and their perspectives on causes, impacts and prevention strategies. Nearly 40% of patients interviewed reported at least one diagnostic error in the past 5 years that adversely impacted their emotional and physical well-being. Qualitative analysis revealed five main themes underlying the causes of diagnostic error: problems with clinical evaluation, limited time with clinicians, poor communication between clinicians and patients or between clinicians, and systems failures. Suggested strategies to reduce diagnostic error included improvements to clinical management, increase patient access to clinicians, communication improvements between patients and clinicians and between clinicians, and self-advocacy by patients.
Newman-Toker DE, Schaffer AC, Yu-Moe CW, et al. Diagnosis (Berl). 2019;6(3):227-240.
Diagnostic errors are widely acknowledged as a common patient safety problem, but difficulty in measuring these errors has made it challenging to quantify their impact. This study utilized a large national database of closed malpractice claims to estimate the frequency and severity of diagnostic errors. Researchers also sought to determine the types of diagnoses most vulnerable to misdiagnosis. Missed or delayed diagnoses accounted for 21% of 55,377 claims analyzed, and the majority of these cases resulted in permanent disability or death. These findings corroborate earlier research on closed malpractice claims in primary care and emergency department settings. Investigators found that three groups of diagnoses accounted for the majority of closed claims and high-severity events: vascular events (such as myocardial infarction and stroke), infections (such as sepsis), and cancer. This study represents an important step forward in identifying areas for improvement in diagnosis, but caution should be exercised in extrapolating these results, since malpractice claims only account for a small proportion of all adverse events experienced by patients. A previous PSNet perspective discussed momentum in the field of diagnostic error over the past several years.
Gupta A, Snyder A, Kachalia A, et al. BMJ Qual Saf. 2017;27(1):53-60.
Characterization of diagnostic error in the hospital setting has traditionally relied on data from autopsy studies, but the continuing decline in autopsy rates necessitates identification of diagnostic errors through other data sources. In this study, investigators utilized the National Practitioner Data Bank to examine the incidence and severity of inpatient diagnostic error and estimate the clinical and economic consequences of these errors. Diagnostic error accounted for 22% of paid malpractice claims over a 12-year period, resulting in $5.7 billion in payments, and the incidence of claims due to failure to diagnose increased over time. Paid claims due to diagnostic error were more likely to be for male patients older than 50, compared with other types of paid claims. Consistent with other studies, a small proportion (9%) of physicians accounted for a large proportion (51%) of payments. Although paid malpractice claims data have important limitations, this study advances our understanding of the epidemiology of diagnostic error among hospitalized patients and insights into possible preventive mechanisms.
Wachter RM. Health Aff (Millwood). 2010;29(9):1605-1610.
This commentary discusses the challenges in measuring diagnostic errors and developing solutions for prevention. The author discusses the potential roles of health information technology, improved training, and increased awareness of diagnostic errors as promising approaches. This commentary is part of a special issue on medical malpractice and errors.
Newman-Toker DE, McDonald KM, Meltzer DO. BMJ Qual Saf. 2013;22(Suppl 2):ii11-ii20.
This commentary uses case examples to demonstrate how economic analysis may help inform efforts to improve the safety of diagnostic decision making.
McDonald KM, Bryce CL, Graber ML. BMJ Qual Saf. 2013;22 Suppl 2:ii33-ii39.
Diagnostic errors are increasingly recognized as an important—and costly—aspect of patient safety. This study advocates for engaging patients to improve diagnostic accuracy in their care and provides tactics to help patients prevent diagnostic errors, including a list of questions to ask their provider. These approaches aim to enhance clinician–patient communication and to help physicians avoid their own cognitive biases. The article also argues for the role of patients as a "crucial voice" in augmenting diagnostic delivery systems, research, and policy. A previous AHRQ WebM&M perspective with Dr. Mark Graber discussed diagnostic errors along with strategies for clinicians to avert cognitive pitfalls.
Graber ML. BMJ Qual Saf. 2013;22 Suppl 2:ii21-ii27.
This review examines eight research methods used to estimate the incidence of diagnostic error and recommends tactics to improve its measurement, including trigger tools and patient reporting.
Tehrani ASS, Lee HW, Mathews SC, et al. BMJ Qual Saf. 2013;22(8):672-680.
The patient safety consequences of diagnostic errors have been receiving greater attention in the past few years, after being relatively neglected in the early period of the safety movement. The results of this study will likely add momentum to this "next frontier" in patient safety. The authors analyzed 25 years of closed malpractice claims from the National Practitioner Data Bank and found that diagnostic errors—primarily in the outpatient setting—were both the most common and the most costly (in terms of total payments) type of claim. Compared with other types of errors, diagnostic errors were more likely to result in serious patient harm or death. Although data from closed malpractice claims may not be representative of all error types, it is clear from this study that diagnostic errors account for a large proportion of preventable patient harm. Recent reviews have identified strategies to improve diagnostic accuracy at the individual clinician level and at the system level. The human costs of a fatal diagnostic error—for the patient and the clinician—were vividly illustrated in a recent graphic-novel style article.
Leape L, Brennan TA, Laird N, et al. N Engl J Med. 1991;324(6):377-84.
The authors analyzed the nature of injuries sustained in a cohort of hospitalized patients in New York in 1984. Physician reviewers evaluated 1133 injury cases with respect to negligence, errors in management, and extent of disability. The reviewers found complications from medications were most common, followed by wound infections and technical complications. Nonsurgical events were more likely to be associated with negligence. The proportion of adverse events due to negligence was highest for diagnostic mishaps, errors of omission, and events in the emergency room, ranging from 70% to 77% in these categories. Errors in management were common as well; nearly half of these cases were attributed to negligence.
Shojania KG, Burton EC, McDonald KM, et al. JAMA. 2003;289(21):2849-2856.
A systematic review of the literature from 1966 to 2002 was performed to determine the rate at which autopsies detect important, clinically missed diagnoses and the extent to which this rate has changed over time. Fifty-three autopsy series were studied that reported diagnoses involving a primary cause of death (major errors) and those likely to have affected patient outcome (class I errors). The median major error rate was 23.5% (4.1% to 49.8%), and the median class I error rate was 9.0%. Over time, there were relative decreases in major errors and class I errors of 19.4% and 33.4% per decade, respectively. Despite these decreases, the authors estimate that for modern U.S. institutions, there is likely a major error rate from 8.4% to 24.4% and a class I error rate from 4.1% to 6.7%.
