Types and Origins of Diagnostic Errors in Primary Care Settings
By Hardeep Singh, T. Giardina, Ashley N. D. Meyer, S. Forjuoh, Michael D. Reis, Eric J. Thomas. 2013
536 citations recorded by the source corpus.
Importance Diagnostic errors are an understudied aspect of ambulatory patient safety. Objectives To determine the types of diseases missed and the diagnostic process involved in the cases of confirmed diagnosis errors in primary care settings and to determine whether record reviews could shed light on potential contributory factors to inform future interventions. Design We reviewed medical records of diagnostic errors detected at two sites through electronic health records-based triggers. Triggers were based on patterns of patients’ unexpected return visits after an initial primary care “index” visit. Setting A larger urban Veterans Affairs facility and a large integrated private health care system. Participants Our study focused on 190 unique instances of diagnostic errors detected in primary care visits between October 1, 2006, and September 30, 2007. Main Outcome Measures Through medical record reviews, we collected data on presenting symptoms at the index visit, types of diagnoses missed, process breakdowns, potential contributory factors, and potential for harm from errors. Results In 190 cases, a total of 68 unique diagnoses were missed. Most missed diagnoses were common conditions in primary care, with pneumonia (6.7%), decompensated congestive heart failure (5.7%), acute renal failure (5.3%), cancer (primary) (5.3%), and urinary tract infection or pyelonephritis (4.8%) being most common. Process breakdowns most frequently involved the patient-practitioner clinical encounter (78.9%) but were also related to referrals (19.5%), patient-related factors (16.3%), follow-up and tracking of diagnostic information (14.7%), and performance and interpretation of diagnostic tests (13.6%). A total of 43.7% of cases involved more than one of these processes. Patient- practitioner encounter breakdowns were primarily related to problems with history-taking (56.3%), examination (47.4%), and/or ordering diagnostic tests for further work-up (57.4%). Most errors were associated with potential for moderate-to-severe harm. Conclusions and Relevance Diagnostic errors identified in our study involved a large variety of common diseases and had significant potential for harm. Most errors were related to process breakdowns in the patient-practitioner clinical encounter. Preventive interventions should target common contributory factors across diagnoses, especially those that involve data gathering and synthesis in the patient- practitioner encounter.
Subfields: Emergency Medical Services, Family Practice, General Health Professions
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Citations in the corpus
- Clinical decision support systems for improving diagnostic accuracy and achieving precision medicine (2015, background): “One study showed missing electronic documentation of differential diagnoses on the index visit in 81.1% of cases [29].”
- The frequency of diagnostic errors in outpatient care: estimations from three large observational studies involving US adult populations (2014, background): “Based on our previous work, 17 we estimated that about one-half of errors would have the potential to lead to severe harm.”
- FHIRChain: Applying Blockchain to Securely and Scalably Share Clinical Data (2018, background): “[3] and errors in treatment plan andmedication Kaushal et al.”
- Early recognition of multiple sclerosis using natural language processing of the electronic health record (2017, background): “In the outpatient setting, the overall missed diagnosis rate has been estimated to be 5% [5, 6] and has been reported to be as high as 20% for various cancers [7] and chronic kidney disease [8].”