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Diagnostic errors that harm outpatients are typically the result of multiple individual and system breakdowns

A study of 307 closed malpractice claims shows that many missed or delayed diagnoses of outpatients lead to dire outcomes. In some cases, diagnosis of a serious condition like cancer was delayed more than a year. Over half (59 percent) of the claims studied involved diagnostic errors that harmed patients. Also, 59 percent of these errors were associated with serious harm, and 30 percent resulted in death. Cancer was the diagnosis involved in 59 percent of the errors, chiefly breast (24 percent) and colorectal (7 percent) cancer. The next most commonly missed diagnoses were infections, fracture, and heart attacks.

The most common breakdowns in the diagnostic process were failure to order an appropriate diagnostic test (55 percent), failure to create a proper followup plan (45 percent), failure to obtain an adequate history or perform an adequate physical exam (42 percent), and incorrect interpretation of diagnostic tests (37 percent) by physicians, radiologists, or pathologists. In some cases, clinicians failed to check on test results or to communicate them to patients, or they did not schedule a necessary followup appointment. In other cases, patients failed to keep an appointment to find out or follow up on abnormal test results.

Missed cancer diagnoses were more likely than other missed diagnoses to involve errors in the performance and interpretation of tests. Primary care physicians were centrally involved in most diagnostic errors. The findings reinforce the need for system interventions, such as clinical decision support systems that include alerts and reminders, to reduce these problems. The study was supported in part by the Agency for Healthcare Research and Quality (HS11886 and HS11285).

More details are in "Missed and delayed diagnoses in the ambulatory setting: A study of closed malpractice claims," by Tejal K. Gandhi, M.D., M.P.H., Allen Kachalia, M.D., J.D., Eric J. Thomas, M.D., M.P.H., and others, in the October 3, 2006, Annals of Internal Medicine 145, pp. 488-496.

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