Known information: Errors related to missed or delayed diagnoses are a frequent cause of patient injury, and an underlying cause of patient safety related events. Autopsy series spanning several decades reveals error rates of 4.1% to 49.8%. Diagnostic errors are encountered in every specialty and are generally lowest (less than 5%) for perceptual specialties (radiology, pathology and dermatology), which rely heavily on visual pattern recognition and interpretation. Error rates in other clinical specialties are higher (10% to 15%), consistent with the added demands of data gathering and synthesis. Additionally, diagnostic errors are frequently the leading or second leading cause of malpractice claims in the United States, accounting for twice as many alleged and settled claims as medication errors. Studies have shown that cognitive errors, and system design flaws - especially communication issues - all contribute to diagnostic error.
Discussion: The Pennsylvania Patient Safety Authority reviewed exactly 100 events related to diagnostic error reported between June 2004 and November 2009 (searching on terms such as delayed diagnosis, wrong diagnosis, missed diagnosis, misdiagnosed, failure to diagnose, failure to treat and medical follow-up) in an effort to determine if there were system solutions to diagnostic error. Potential outcome and process measures for detecting diagnostic error are reviewed and both cognitive and system-related risk reduction strategies to reduce diagnostic error are presented.
See more of: The 32nd Annual Meeting of the Society for Medical Decision Making