Diagnostic Error: A Missed Opportunity to Improve Patient Safety?

By Peter Bonis | Published 4/22/2018 4

Distraught female doctor holding X-ray 1430 x 1015

A consensus committee defined diagnostic error as the failure to establish an accurate and timely explanation of a patient’s health problem and communicate the explanation to the patient. The impact of diagnostic error based on this definition is reflected in sobering observations.

  • Diagnostic errors contribute to 10 percent of deaths according to autopsy studies
  • They are twice as likely to have resulted in a patient’s death compared with other types of errors
  • Between 6 and 17% of adverse events in hospitalized patients are attributed to diagnostic errors.
  • Five percent of adults in the United States who seek outpatient care experience a diagnostic error.

The costs are no less troublesome: one report from the United States suggests diagnostic errors cost at least $17 billion annually. Adding to the costs is the observation that diagnostic errors are the leading cause of medical malpractice claims.

Diagnostic error is complex

Diagnostic error is complex. It results from a breakdown of the diagnostic process, in which the proper diagnosis and resulting actions evolve iteratively from interactions with a caregiver, patient, and the healthcare system. Examples include failure to recognize opioid intoxication in a patient with mental status changes, failure to consider pulmonary embolism in a patient with shortness of breath, incorrect diagnosis of iron deficiency anemia in a patient with a pre-malignant blood condition, an incomplete physical examination leading to a missed diagnosis of appendicitis, failure to communicate an abnormal chest x-ray finding leading to the delayed diagnosis of lung cancer.

Several recommendations have been endorsed broadly to reduce diagnostic errors. They emphasize efforts to do the following:

    • Facilitate effective teamwork in the diagnostic process
    • Enhance education and training
    • Encourage the use of health information technologies to support the diagnostic process
    • Achieve methods to learn from errors
    • Establish a culture that encourages better diagnostic performance,
    • Develop a reporting environment and liability system that facilitates learning from errors
    • Design a payment and care delivery environment that supports the diagnostic process, and
    • Provide funding for research on diagnostic errors.

Related content: Diagnostic errors are more common than you might think.

Barriers to reducing diagnostic errors

Unfortunately, due to several barriers that have impeded progress, these recommendations have not yet been adopted widely. Competing initiatives, particularly the implementation of health information technology systems and compliance with regulatory, billing, and reporting requirements, within healthcare systems have hindered progress. In addition, financial constraints among healthcare systems make it difficult to gain enterprise-wide commitment to these initiatives. And lack of requirement for public reporting of diagnostic errors means the scale of the problem isn’t always apparent within healthcare practices.

The economic impetus to tackle diagnostic errors remains largely rooted in the beneficence of healthcare providers, the fear of malpractice litigation, and, to a lesser extent, the recognition that diagnostic errors can be costly. On the last point, the costs of diagnostic errors, under a fee-for-service system, are not always born by those providing the care. As a result, there is limited incentive to prioritize efforts to reduce diagnostic errors compared to other initiatives more directly tied to reimbursement, regulations, or costs.

Related Content: The Why and How of Diagnostic Errors

Nevertheless, progress is being made

The considerations above translate into the lack of a strong business model that supports innovation in technological solutions to reduce diagnostic errors. Nevertheless, there has been measured progress. The adoption of electronic medical record systems permits some forms of diagnostic error to be more easily detected and prevented. For example, digital systems are in place that can ensure that abnormal laboratory or imaging results are communicated to the appropriate personnel. In addition, a number of software tools and other interventions have been developed that help clinicians improve clinical reasoning, thereby reducing cognitive errors that lead to a breakdown of the diagnostic process. Most of these have not been implemented widely, and some that have been adopted, such as tools to aid clinicians in achieving a list of possible diagnoses, have limited benefit. 

Clinical decision support (CDS) has also shown promise but data are still evolving. Defined broadly, CDS is a means to provide clinicians intelligently filtered information at the appropriate time to improve healthcare processes and outcomes.

Investigators at a Tokyo-based acute care hospital found that a popular decision support resource had an important impact on diagnostic error. The study compared rates of diagnostic errors made by clinicians equipped with the CDS system during 50 outpatient visits with 50 control patients cared for by clinicians without access to such a system. The authors observed significantly lower rates of diagnostic errors among clinicians who had access to the resource (2 versus 24 percent) even after considering factors such as the patient’s age, sex, primary diagnosis and case difficulty.

The answers to addressing diagnostic errors are not simple and they will require a holistic approach that healthcare systems are only starting to tackle. In the near term, today’s CDS capabilities already demonstrate the potential to substantially reduce diagnostic errors and improve patient outcomes.

Peter Bonis

Website: http://healthclarity.wolterskluwer.com/hc.html

Peter A. L. Bonis, M.D., is the chief medical officer for Clinical Effectiveness at Wolters Kluwer Health as well Adjunct Professor of Medicine, Tufts University School of Medicine. Dr. Bonis trained in gastroenterology and health services research, and before joining UpToDate in 1998, he was a full-time faculty member at Yale University School of Medicine.


  • It is ironic to read this article and NOT to see any reference to the role that the patient should play in the diagnostic practice. With the errors that exist in medical records, including the basic personal identification, failure to note allergies to medications, lack of relevant family histories, and inaccurate diagnoses from earlier treatments, patients are often put in peril. As a minimum, this is inefficient and costly care. Patients should have ready access to all their records, the ability to correct the errors, and be aware of the reasons for any working diagnosis. Simply learning to ask, “What else could it be?” or “How did you come to that conclusion?” in regard to a diagnosis, the patient might remind both the doctor and himself that there needs to be a rationale for that diagnosis. That alone might help both parties monitor the treatment and responses which may follow.

    • Excellent addition to the conversation, thanks Peggy. I am a big fan of patients having access to all of their records, doing their own research about the problem and getting second opinions to ensure their diagnosis is as good as it can be.

  • Good article. Mayo published a report several years ago that suggested that about 32% of all elective surgery is base on a misdiagnosis. That costs about $600 Billion a year.

Leave a Reply

Your email address will not be published. Required fields are marked *

This site uses Akismet to reduce spam. Learn how your comment data is processed.

Comment will held for moderation