Malpractice Risks When Diagnosing Patients; More

Wayne J. Guglielmo, MA


March 17, 2015

In This Article

New Report Highlights the Source of Diagnostic Errors

Over the past 15 years, healthcare providers and risk managers have made steady progress in identifying and addressing the underlying causes of malpractice in such clinical areas as medication management, obstetrical care, and surgery. Less attention, however, has been paid to errors in another area of medical care—one where errors are more common than in obstetrics and more costly than in surgery. This area is the diagnostic process, according to a recently released report by CRICO Strategies, a division of the Risk Management Foundation of the Harvard Medical Institutions.[1]

Report findings were drawn from CRICO's substantial malpractice database, which contains more than 300,000 open and closed cases, representing upwards of 400 hospitals and 165,000 physicians. Examining 23,527 cases filed from 2008 to 2012, researchers found that claimants alleged diagnostic failures in 20% of them. (Surgical care was implicated in 28% of the other cases, general medical treatment in 23%, and obstetrics in 7%; the remaining 22% of cases were broadly categorized as "other.")

Researchers further divided the subset of diagnostic-related cases—slightly over 4700—into three categories: emergency department (ED) care, inpatient care, and ambulatory care. They found that most of the diagnostic failures—57% (2685 cases)—occurred in ambulatory care, where the top three missed diagnoses involved cancer, heart disease, and orthopedic injuries. Inpatient care was next on the list of problematic areas with 26% (1223 cases), followed by ED care with 16% (752 cases).

Given their position in the front line of patient care, it should come as no surprise that family physicians and internal medicine doctors (along with other doctors of medicine, including gastroenterologists) accounted for 49% of the diagnostic failures in ambulatory care. Surgeons and radiologists were involved in 17% and 15%, respectively. Pathologists and a broad group of "other" physicians were involved in the remaining 19% of cases.

The study traced nearly three quarters of the diagnostic failures in ambulatory care to lapses in clinical judgment, followed by patient compliance (25%) and communication breakdowns (24%). (Most cases included more than one factor.) The top three lapses in clinical judgment were delay in or failure to order a diagnostic test (31%), misinterpretation of a diagnostic test (23%), and failure to establish a differential diagnosis (22%).

A major goal of the report, company officials say, is to identify those points along the diagnostic continuum where better physician training—along with improvements in the medical delivery system—could significantly reduce errors. By this measure, two clinical areas merit special attention: the initial diagnostic assessment, and follow-up and coordination. Of the roughly 4700 diagnostic-related cases that CRICO researchers identified, problems in initial assessment and follow-up and coordination were involved in 58% and 46% of these cases, respectively.

"We hope this report accelerates the development and adoption of a broader set of effective solutions to the cognitive and systemic problems that can impede prompt and accurate diagnoses," says Heather Riah, assistant vice president of CRICO Strategies.


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