THE MOST COMMONLY MISSED DIAGNOSES IN PRIMARY CARE

Background:  The most common cause of diagnostic error is failure to consider the correct diagnosis as a possibility.  The purpose of this study was to identify the most commonly missed diagnoses in primary care, as well as the most common presenting complaints and initial (incorrect) diagnoses associated with these missed diagnoses.

Methods:  We mailed a one-page questionnaire to a random sample of 600 Iowa physicians (200 family physicians, 200 general internists, and 200 general pediatricians).  Respondents described one of their diagnostic errors using 5 prompts, which asked for (1) the presenting complaint, (2) the initial (wrong) diagnosis, (3) the final (missed) diagnosis, (4) the patient's outcome, (5) the physician's personal "take-home" message."

Results:  The response rate was 30% (182/600).  The most common presenting complaints were fever (18 cases, 9.9% of 182); fatigue (15, 8.2%); dyspnea (12, 6.6%); abdominal pain (11, 6.0%); and chest pain (9, 5.0%).  The most common initial (wrong) diagnoses were viral infection (30, 16.5%); musculoskeletal pain (21, 11.5); chronic obstructive lung disease/asthma (13, 7.1%); benign skin conditions (9, 5.0%); and pneumonia (8, 4.4%).  The most common final (missed) diagnoses were cancer (31 cases, 17.0% of 182); pulmonary embolus (13, 7.1%); ruptured aneurysm (8, 4.4%); acute coronary syndrome (8, 4.4%); and meningitis (5, 2.8%).  The most commonly missed cancers were colorectal (5 of 30, 16.7%); lung (5, 16.7%); lymphoma (4, 13.3%); and ovary (3, 10.0%).  Following the error, 62 patients (34.1% of 182) had no serious consequences, 49 (26.9%) died, 29 (15.9%) were temporarily disabled, and 20 (11.0%) were permanently disabled.  The take-home message for most physicians (46 of 182, 25.3%) involved a disease-specific caveat; e.g., "Any discomfort above the umbilicus may be coronary disease."  The next most common take-home messages included variations of "Look beyond your initial diagnosis or broaden your differential diagnosis" (34 of 182, 18.7%); "Be more aggressive with diagnostic testing" (14, 7.7%); "If things are not going as expected, reassess" (14, 7.7%); and "Do a more thorough physical exam (9, 5.0%).

Conclusion: In most cases the complaints were common, the initial diagnoses were benign, and the final (missed) diagnoses were less common and more serious.  A better understanding of the most commonly missed diagnoses may allow more focused efforts toward prevention of diagnostic errors.  These efforts might include a list of high-risk presentations that should prompt diagnostic "time-outs" to slow down and broaden the list of diagnostic considerations.