Patient Safety and Quality

Over half of missed diagnoses in the emergency department alleged in malpractice claims resulted in harm to patients

Of 122 closed malpractice claims, 65 percent involved missed emergency department (ED) diagnoses that harmed patients. Nearly half (48 percent) of these missed diagnoses were associated with serious harm, and 39 percent resulted in death, according to a new study. The leading breakdowns in the diagnostic process were failure to order an appropriate diagnostic test (58 percent of errors), failure to perform an adequate medical history or physical examination (42 percent), incorrect interpretation of a diagnostic test (37 percent), and failure to order an appropriate consultation (33 percent).

Types of missed diagnoses ranged from fractures and infections to heart attack and cancer, problems that comprised half the cases. The cause of missed diagnoses was complex, with the majority involving multiple breakdowns in the diagnostic process, several contributing factors, and more than one provider. The most common contributing factors were mistakes in judgment (87 percent of missed diagnoses), lack of technical competence or knowledge (58 percent), and lapses in vigilance or memory (41 percent).

These cognitive factors operated alone in one-third of missed diagnoses; in two-thirds of cases other factors also contributed to the missed diagnoses. Other leading contributing factors to missed diagnoses included patient-related factors (34 percent), lack of appropriate ED staff supervision (30 percent), inadequate handoffs of patients to new staffers (24 percent), and excessive workload (23 percent).

A median of two process breakdowns and three contributing factors were involved in each missed diagnosis. The findings were based on a review of the closed files of 122 malpractice claims alleging missed or delayed diagnosis in the ED. The study was supported by the Agency for Healthcare Research and Quality (HS11886 and HS11285).

See "Missed and delayed diagnoses in the emergency department: A study of closed malpractice claims from 4 liability insurers," by Allen Kachalia, M.D., J.D., Tejal K. Gandhi, M.D., M.P.H., Ann Louise Puopolo, B.S.N., R.N., and others, in the February 2007 Annals of Emergency Medicine 49(2), pp. 196-205.

Editor's Note: Another AHRQ-supported study on medical errors (HS11878) found that the response to medical mistakes by the medical community influenced how rural victims of mistakes perceived the mistake and resulting harm. For more details, see: Van Vorst, R.F., Araya-Guerra, R., Felzien, M., and others (2007, March). "Rural community members' perceptions of harm from medical mistakes: A high plans research network (HPRN) study." Journal of the American Board of Family Medicine 20, pp. 135-143.

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