About Diagnostic Errors

According to a review of more than 350,000 paid claims from 1986 to 2010 included in the National Practitioner Data Bank, diagnostic errors generate more medical liability payments than any other medical error. (1)  

Yet determining the prevalence of diagnostic errors is challenging, particularly outside the fields of pathology and radiology. With the decline in autopsy rates, physicians do not generally receive feedback on their diagnoses. As a result, “diagnostic errors often are unrecognized or under-reported.” (2)

Understanding diagnostic errors

‍Research into the causes of diagnostic errors has been influenced by findings from cognitive psychology, which classifies tasks as involving schematic behavior or attentional behavior. Schematic behavior tasks are performed reflexively or on auto- pilot. Attentional behavior tasks require active planning and problem solving.

Errors associated with schematic behavior are known as “slips” and occur due to distractions, fatigue, or lapses in concentration. Errors related to attentional behavior are “mistakes” and are often caused by a lack of experience or training.

In health care, the majority of errors are caused by slips. Interventions such as checklists have been shown to greatly reduce the likelihood of errors due to slips. (3) Conversely, errors that involve attentional behavior — such as diagnostic errors — “require solutions focused on training, supervision, and decision support rather than standardizing behavior.” (4)

Yet, diagnostic errors are not simply a consequence of cognitive errors on the part of caregivers. They result from multiple causes, such as poor teamwork and communication between physicians; poor communication between patients and physicians or patients and staff members; lack of reliable systems for following up on test results; and patient noncompliance. Underlying health system issues — such as health insurance refusal to pay for diagnostic testing — also contribute to errors in diagnosis.

A study of diagnostic errors in the ambulatory setting published in the Annals of Internal Medicine found that very few diagnostic errors were linked to single contributing factors. The study identified the following as main breakdowns in the diagnostic process:

• failure to order appropriate diagnostic tests;
• inappropriate or inadequate follow up;
• failure to obtain an adequate medical history;
• failure to perform an adequate physical exam; and
• incorrect interpretation of diagnostic test results. (4)

Preventing diagnostic errors

‍Consider the following guidelines to help reduce liability related to errors in diagnosis.

• Stay current with clinical practice standards that are applicable to your practice. Consider using computer-based decision support tools or other electronic resources at the point of care. If you use these resources, do not ignore the guidelines, alerts, and reminders these systems employ.
• Make an accurate diagnosis by asking the right questions, conducting a thorough physical exam, reviewing the medical records, and gathering clinical data.
• When possible, follow up with patients to ensure diagnostic accuracy. Repeated calls or visits from patients with ongoing symptoms provide the opportunity to reassess the patient and identify an issue that may have been overlooked.
• Have a well-defined and consistently followed process to verify that test results have been received and acted upon. Processes should be developed for both diagnostic studies and specialist referrals.
• Even if the patient is advised to contact the practice in a set time frame, it is beneficial for the physician to have a follow-up system in place.
• When test results or consultant reports are received in the office, do not add the reports in the medical record until the ordering physician has reviewed them.
• When caring for hospitalized patients, maintain open communication with all members of the health care team, including consulting physicians and hospital staff. Thorough patient evaluation and assessment — including reviewing nursing notes and directly communicating with consulting physicians — promotes optimal patient care.

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Sources
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1. Saber Tehrani AS, Lee H, Mathews SC, Shore A, Makary MA, et al. 25-Year summary of US malpractice claims for diagnostic errors 1986-2010: an analysis from the National Practitioner Data Bank. BMJ Qual Saf. 2013 Aug;22(8):672-80. Available at https://pubmed.ncbi.nlm.nih.gov/23610443/ Accessed February 11, 2025

2. Newman-Toker DE, Pronovost PJ. Diagnostic errors — the next frontier for patient safety. JAMA. March 11, 2009. 301;(10):1060-1062. Available at https://jamanetwork.com/journals/jama/article-abstract/183516 . Accessed December 3, 2024.

3. Haynes AB, Weiser TG, Berry WR, et al for the Safe Surgery Saves Lives Study Group. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360:491-499. Available at https://www.nejm.org/doi/full/10.1056/NEJMsa0810119 . Accessed December 3, 2024.

4. Bishop TF, Ryan AM, Ryan AK, et al. Paid malpractice claims for adverse events in inpatient and outpatient settings. JAMA 2011. Available at https://jamanetwork.com/journals/jama/fullarticle/900983. Accessed December 3, 2024.

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