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Analysis of 583 Physician-Reported Errors

Gordon D. Schiff, MD; Omar Hasan, MD; Seijeoung Kim, RN, PhD; Richard Abrams, MD; Karen Cosby, MD; Bruce L. Lambert, PhD; Arthur S. Elstein, PhD; Scott Hasler, MD; Martin L. Kabongo, MD; Nela Krosnjar; Richard Odwazny, MBA; Mary F. Wisniewski, RN; Robert A. McNutt, MD

Arch Intern Med. 2009;169(20):1881-1887.

Background  Missed or delayed diagnoses are a common but understudied area in patient safety research. To better understand the types, causes, and prevention of such errors, we surveyed clinicians to solicit perceived cases of missed and delayed diagnoses.

Methods  A 6-item written survey was administered at 20 grand rounds presentations across the United States and by mail at 2 collaborating institutions. Respondents were asked to report 3 cases of diagnostic errors and to describe their perceived causes, seriousness, and frequency.

Results  A total of 669 cases were reported by 310 clinicians from 22 institutions. After cases without diagnostic errors or lacking sufficient details were excluded, 583 remained. Of these, 162 errors (28%) were rated as major, 241 (41%) as moderate, and 180 (31%) as minor or insignificant. The most common missed or delayed diagnoses were pulmonary embolism (26 cases [4.5% of total]), drug reactions or overdose (26 cases [4.5%]), lung cancer (23 cases [3.9%]), colorectal cancer (19 cases [3.3%]), acute coronary syndrome (18 cases [3.1%]), breast cancer (18 cases [3.1%]), and stroke (15 cases [2.6%]). Errors occurred most frequently in the testing phase (failure to order, report, and follow-up laboratory results) (44%), followed by clinician assessment errors (failure to consider and overweighing competing diagnosis) (32%), history taking (10%), physical examination (10%), and referral or consultation errors and delays (3%).

Conclusions  Physicians readily recalled multiple cases of diagnostic errors and were willing to share their experiences. Using a new taxonomy tool and aggregating cases by diagnosis and error type revealed patterns of diagnostic failures that suggested areas for improvement. Systematic solicitation and analysis of such errors can identify potential preventive strategies.

Author Affiliations: Departments of Medicine (Drs Schiff and Kim and Mss Krosnjar and Wisniewski) and Emergency Medicine (Dr Cosby), Cook County Hospital, Chicago, Illinois; Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts (Drs Schiff and Hasan); Department of Medicine, Rush University, Chicago (Drs Schiff, Abrams, Hasler, and McNutt and Mr Odwazny); Departments of Health Policy and Administration (Dr Kim) and Medical Education (Dr Elstein) and College of Pharmacy (Dr Lambert), University of Illinois at Chicago; and Department of Family and Preventive Medicine, University of California, San Diego (Dr Kabongo).

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