Advanced searchCitation search
Skip main navigation
Close Drawer MenuOpen Drawer Menu
Articles3 October 2006

Missed and Delayed Diagnoses in the Ambulatory Setting: A Study of Closed Malpractice Claims

    Author, Article, and Disclosure Information
    https://doi.org/10.7326/0003-4819-145-7-200610030-00006

    Abstract

    Background:

    Although missed and delayed diagnoses have become an important patient safety concern, they remain largely unstudied, especially in the outpatient setting.

    Objective:

    To develop a framework for investigating missed and delayed diagnoses, advance understanding of their causes, and identify opportunities for prevention.

    Design:

    Retrospective review of 307 closed malpractice claims in which patients alleged a missed or delayed diagnosis in the ambulatory setting.

    Setting:

    4 malpractice insurance companies.

    Measurements:

    Diagnostic errors associated with adverse outcomes for patients, process breakdowns, and contributing factors.

    Results:

    A total of 181 claims (59%) involved diagnostic errors that harmed patients. Fifty-nine percent (106 of 181) of these errors were associated with serious harm, and 30% (55 of 181) resulted in death. For 59% (106 of 181) of the errors, cancer was the diagnosis involved, chiefly breast (44 claims [24%]) and colorectal (13 claims [7%]) cancer. The most common breakdowns in the diagnostic process were failure to order an appropriate diagnostic test (100 of 181 [55%]), failure to create a proper follow-up plan (81 of 181 [45%]), failure to obtain an adequate history or perform an adequate physical examination (76 of 181 [42%]), and incorrect interpretation of diagnostic tests (67 of 181 [37%]). The leading factors that contributed to the errors were failures in judgment (143 of 181 [79%]), vigilance or memory (106 of 181 [59%]), knowledge (86 of 181 [48%]), patient-related factors (84 of 181 [46%]), and handoffs (36 of 181 [20%]). The median number of process breakdowns and contributing factors per error was 3 for both (interquartile range, 2 to 4).

    Limitations:

    Reviewers were not blinded to the litigation outcomes, and the reliability of the error determination was moderate.

    Conclusions:

    Diagnostic errors that harm patients are typically the result of multiple breakdowns and individual and system factors. Awareness of the most common types of breakdowns and factors could help efforts to identify and prioritize strategies to prevent diagnostic errors.

    References

    • 1. Haas JS, Cook EF, Puopolo AL, Burstin HR, Brennan TA. Differences in the quality of care for women with an abnormal mammogram or breast complaint. J Gen Intern Med. 2000;15:321-8. [PMID: 10840267] CrossrefMedlineGoogle Scholar
    • 2. Marcus AC, Crane LA, Kaplan CP, Reading AE, Savage E, Gunning J, et al. Improving adherence to screening follow-up among women with abnormal Pap smears: results from a large clinic-based trial of three intervention strategies. Med Care. 1992;30:216-30. [PMID: 1538610] CrossrefMedlineGoogle Scholar
    • 3. Poon EG, Gandhi TK, Sequist TD, Murff HJ, Karson AS, Bates DW. “I wish I had seen this test result earlier!”: dissatisfaction with test result management systems in primary care. Arch Intern Med. 2004;164:2223-8. [PMID: 15534158] CrossrefMedlineGoogle Scholar
    • 4. Margo CE. A pilot study in ophthalmology of inter-rater reliability in classifying diagnostic errors: an underinvestigated area of medical error. Qual Saf Health Care. 2003;12:416-20. [PMID: 14645756] CrossrefMedlineGoogle Scholar
    • 5. Bates DW, Cullen DJ, Laird N, Petersen LA, Small SD, Servi D, et al. Incidence of adverse drug events and potential adverse drug events. Implications for prevention. ADE Prevention Study Group. JAMA. 1995;274:29-34. [PMID: 7791255] CrossrefMedlineGoogle Scholar
    • 6. Leape LL, Bates DW, Cullen DJ, Cooper J, Demonaco HJ, Gallivan T, et al. Systems analysis of adverse drug events. ADE Prevention Study Group. JAMA. 1995;274:35-43. [PMID: 7791256] CrossrefMedlineGoogle Scholar
    • 7. Chandra A, Nundy S, Seabury SA. The growth of physician medical malpractice payments: evidence from the national practitioner data bank. Health Aff (Millwood). 2005;:W5240-9. [PMID: 15928255] CrossrefMedlineGoogle Scholar
    • 8. Phillips RL, Bartholomew LA, Dovey SM, Fryer GE, Miyoshi TJ, Green LA. Learning from malpractice claims about negligent, adverse events in primary care in the United States. Qual Saf Health Care. 2004;13:121-6. [PMID: 15069219] CrossrefMedlineGoogle Scholar
    • 9. Kern KA. Medicolegal analysis of bile duct injury during open cholecystectomy and abdominal surgery. Am J Surg. 1994;168:217-22. [PMID: 8080055] CrossrefMedlineGoogle Scholar
    • 10. Kern KA. Malpractice litigation involving laparoscopic cholecystectomy. Cost, cause, and consequences. Arch Surg. 1997;132:392-8. [PMID: 9108760] CrossrefMedlineGoogle Scholar
    • 11. Kravitz RL, Rolph JE, McGuigan K. Malpractice claims data as a quality improvement tool. I. Epidemiology of error in four specialties. JAMA. 1991;266:2087-92. [PMID: 1920696] CrossrefMedlineGoogle Scholar
    • 12. Weiler PC, Hiatt HH, Newhouse JP, Johnson WG, Brennan T, Leape LL. A Measure of Malpractice: Medical Injury, Malpractice Litigation, and Patient Compensation. Cambridge, MA: Harvard Univ Pr; 1993. Google Scholar
    • 13. Studdert DM, Brennan TA, Thomas EJ. Beyond dead reckoning: measures of medical injury burden, malpractice litigation, and alternative compensation models from Utah and Colorado. Indiana Law Rev. 2000;33:1643-86. Google Scholar
    • 14. Sowka M, eds. National Association of Insurance Commissioners. Malpractice Claims: Final Compilation. Brookfield, WI: National Association of Insurance Commissioners; 1980. Google Scholar
    • 15. Thomas EJ, Studdert DM, Burstin HR, Orav EJ, Zeena T, Williams EJ, et al. Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care. 2000;38:261-71. [PMID: 10718351] CrossrefMedlineGoogle Scholar
    • 16. Kohn LT, Corrigan JM, Donaldson MS. To Err Is Human. Building a Safer Health System. Institute of Medicine. Washington, DC: National Academy Pr; 1999. Google Scholar
    • 17. Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG, et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med. 1991;324:370-6. [PMID: 1987460] CrossrefMedlineGoogle Scholar
    • 18. Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977;33:159-74. [PMID: 843571] CrossrefMedlineGoogle Scholar
    • 19. Reason J. Managing the Risks of Organizational Accidents. Brookfield, VT: Ashgate; 1997. Google Scholar
    • 20. Harvard Risk Management Foundation. Breast care management algorithm: improving breast patient safety. Accessed at www.rmf.harvard.edu/files/flash/breast-care-algorithm/index.htm on 9 August 2006. Google Scholar
    • 21. Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med. 2003;78:775-80. [PMID: 12915363] CrossrefMedlineGoogle Scholar
    • 22. Graber M, Gordon R, Franklin N. Reducing diagnostic errors in medicine: what's the goal? Acad Med. 2002;77:981-92. [PMID: 12377672] CrossrefMedlineGoogle Scholar
    • 23. Elstein AS, Schwarz A. Clinical problem solving and diagnostic decision making: selective review of the cognitive literature. BMJ. 2002;324:729-32. [PMID: 11909793] CrossrefMedlineGoogle Scholar
    • 24. Schoen C, Osborn R, Huynh PT, Doty M, Davis K, Zapert K, et al. Primary care and health system performance: adults' experiences in five countries. Health Aff (Millwood). 2004; suppl W4-487-503. [PMID: 15513956] MedlineGoogle Scholar
    • 25. Kawamoto K, Houlihan CA, Balas EA, Lobach DF. Improving clinical practice using clinical decision support systems: a systematic review of trials to identify features critical to success. BMJ. 2005;330:765. [PMID: 15767266] CrossrefMedlineGoogle Scholar
    • 26. Friedman CP, Gatti GG, Franz TM, Murphy GC, Wolf FM, Heckerling PS, et al. Do physicians know when their diagnoses are correct? Implications for decision support and error reduction. J Gen Intern Med. 2005;20:334-9. [PMID: 15857490] CrossrefMedlineGoogle Scholar
    • 27. Joint Commission on Accreditation of Healthcare Organizations. National Patient Safety Goals. Accessed at www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/07_amb_obs_npsgs.htm on 9 August 2006. Google Scholar
    • 28. Gandhi TK. Fumbled handoffs: one dropped ball after another. Ann Intern Med. 2005;142:352-8. [PMID: 15738454] LinkGoogle Scholar
    • 29. Guthrie C, Rachlinski JJ, Wistrich AJ. Inside the judicial mind. Cornell Law Rev. 2001;86:777-830. Google Scholar
    • 30. LaBine SJ, LaBine G. Determinations of negligence and the hindsight bias. Law Hum Behav. 1996;20:501-16. CrossrefGoogle Scholar
    • 31. Studdert DM, Mello MM, Gawande AA, Gandhi TK, Kachalia A, Yoon C, et al. Claims, errors, and compensation payments in medical malpractice litigation. N Engl J Med. 2006;354:2024-33. [PMID: 16687715] CrossrefMedlineGoogle Scholar
    • 32. Burstin HR, Johnson WG, Lipsitz SR, Brennan TA. Do the poor sue more? A case–control study of malpractice claims and socioeconomic status. JAMA. 1993;270:1697-701. [PMID: 8411499] CrossrefMedlineGoogle Scholar
    • 33. Studdert DM, Thomas EJ, Burstin HR, Zbar BI, Orav EJ, Brennan TA. Negligent care and malpractice claiming behavior in Utah and Colorado. Med Care. 2000;38:250-60. [PMID: 10718350] CrossrefMedlineGoogle Scholar
    • 34. Brennan TA, Gawande A, Thomas E, Studdert D. Accidental deaths, saved lives, and improved quality. N Engl J Med. 2005;353:1405-9. [PMID: 16192489] CrossrefMedlineGoogle Scholar
    Previous
    Next

    Submit a Comment

    Contributors must reveal any conflict of interest. Comments are moderated. Please see our information for authorsregarding comments on an Annals publication.
    *All comments submitted after October 1, 2021 and selected for publication will be published online only.
    Cancel