Medical errors caused by missed and delayed diagnoses in the outpatient setting result in significant harm to patients, according to a recent review of medical malpractice claims (Ann Intern Med. 2006;145:488-496).

Diagnostic errors were involved in nearly 60% of the malpractice claims studied, and nearly one third of these errors were associated with a patient’s death. The study is one of the first to look at potential causes of medical errors in health-care settings other than hospitals.


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Researchers at Brigham and Women’s Hospital and the Harvard School of Public Health in Boston analyzed 307 claims from four liability insurers; 181 were determined to have involved diagnostic errors that led to an adverse outcome. Cancer (notably breast and colorectal) was the most common missed diagnosis.


Failure to order appropriate tests was the most frequent cause of the breakdown in the diagnostic process, followed by failure to create a proper follow-up plan, failure to obtain an adequate history or perform an adequate physical examination, and incorrect interpretation of test results.


In trying to pin down why the diagnostic process failed, researchers found that missed cancer diagnoses were more likely to involve tests that were incorrectly performed (13%) or misinterpreted (46%). In contrast, missed noncancer diagnoses (e.g., infection, fracture, and MI) more often resulted from delays by patients in seeking care, inadequate patient histories or physical examinations, or failure to refer for additional follow-up care.


Because of the nature of the diagnostic process, there is no magic bullet to prevent errors. Nevertheless, the authors identify three vulnerable areas—ordering decisions, test interpretation, and follow-up planning—as useful starting points from which to craft prevention strategies. Specifically, the use of electronic health records, improved algorithms for patient evaluations, and help from nurse practitioners to ensure patients receive appropriate follow-up care might help reduce the number of physician errors.