DO DIAGNOSTIC REASONING FAULTS ALWAYS RESULT IN DIAGNOSTIC ERRORS OR PATIENT HARM?

Background: The present study aims to examine the occurrence and causes of faults in the diagnostic reasoning process (suboptimal cognitive acts) and relate them to diagnostic error and patient harm.

Methods: Physicians included 247 dyspnea patients in the study whose patient records were reviewed by expert internists. A questionnaire to review the diagnostic reasoning process was developed using the Dephi-method. The record review focused on detecting suboptimal cognitive acts, diagnostic error and patient harm. The findings of the record reviews were discussed with the treating physicians and subsequently classified using Reasons’ taxonomy of unsafe acts.

Results: Suboptimal cognitive acts (such as, incomplete medical history taking, or not performing a necessary EKG) occurred in 66% of all cases. In 13.8% of all cases a diagnostic error occurred and in 11.3% the patient was harmed. There was an overlap between cases with diagnostic errors and cases with patient harm of 3.2%. Diagnostic error and patient harm more often occurred in cases with more suboptimal cognitive acts. However, diagnostic errors and patient harm also occurred in cases where no suboptimal cognitive act were involved (e.g. due to complications). Based on the expert judgments and the interviews with the treating physicians, the causes were mostly classified as mistakes (46%) and slips (18%).

Conclusion: Diagnostic errors and patient harm were associate with more suboptimal cognitive acts. There was, however, no complete overlap between these three components. Diagnostic errors and patient harm also occurred when no faults were involved.Often, more than one suboptimal cognitive act occurred in cases with diagnostic errors and patient harm suggesting that a series of suboptimal cognitive acts were involved. Mistakes and slips were mostly seen as causes of suboptimal cognitive acts. This implies that physicians did not realize their actions were incorrect. More supervision could be a way to reduce diagnostic errors.