Missed and delayed diagnoses in the ambulatory setting: A study of closed malpractice claims

Tejal K. Gandhi, Allen Kachalia, Eric J. Thomas, Ann Louise Puopolo, Catherine Yoon, Troyen A. Brennan, David M. Studdert

Research output: Contribution to journalArticle

Abstract

Background: Although missed and delayed diagnoses have become an important patient safety concern, they remain largely unstudied, especially in the outpatient setting. Objective: To develop a framework for investigating missed and delayed diagnoses, advance understanding of their causes, and identify opportunities for prevention. Design: Retrospective review of 307 closed malpractice claims in which patients alleged a missed or delayed diagnosis in the ambulatory setting. Setting: 4 malpractice insurance companies. Measurements: Diagnostic errors associated with adverse outcomes for patients, process breakdowns, and contributing factors. Results: A total of 181 claims (59%) involved diagnostic errors that harmed patients. Fifty-nine percent (106 of 181) of these errors were associated with serious harm, and 30% (55 of 181) resulted in death. For 59% (106 of 181) of the errors, cancer was the diagnosis involved, chiefly breast (44 claims [24%]) and colorectal (13 claims [7%]) cancer. The most common breakdowns in the diagnostic process were failure to order an appropriate diagnostic test (100 of 181 [55%]), failure to create a proper follow-up plan (81 of 181 [45%]), failure to obtain an adequate history or perform an adequate physical examination (76 of 181 [42%]), and incorrect interpretation of diagnostic tests (67 of 181 [37%]). The leading factors that contributed to the errors were failures in judgment (143 of 181 [79%]), vigilance or memory (106 of 181 [59%]), knowledge (86 of 181 [48%]), patient-related factors (84 of 181 [46%]), and handoffs (36 of 181 [20%]). The median number of process breakdowns and contributing factors per error was 3 for both (interquartile range, 2 to 4). Limitations: Reviewers were not blinded to the litigation outcomes, and the reliability of the error determination was moderate. Conclusions: Diagnostic errors that harm patients are typically the result of multiple breakdowns and individual and system factors. Awareness of the most common types of breakdowns and factors could help efforts to identify and prioritize strategies to prevent diagnostic errors.

Original languageEnglish (US)
Pages (from-to)488-496
Number of pages9
JournalAnnals of internal medicine
Volume145
Issue number7
DOIs
StatePublished - Oct 3 2006
Externally publishedYes

Fingerprint

Delayed Diagnosis
Malpractice
Diagnostic Errors
Routine Diagnostic Tests
Patient Harm
Jurisprudence
Patient Safety
Insurance
Physical Examination
Neoplasms
Breast
Outpatients
History

ASJC Scopus subject areas

  • Internal Medicine

Cite this

Missed and delayed diagnoses in the ambulatory setting : A study of closed malpractice claims. / Gandhi, Tejal K.; Kachalia, Allen; Thomas, Eric J.; Puopolo, Ann Louise; Yoon, Catherine; Brennan, Troyen A.; Studdert, David M.

In: Annals of internal medicine, Vol. 145, No. 7, 03.10.2006, p. 488-496.

Research output: Contribution to journalArticle

Gandhi, Tejal K. ; Kachalia, Allen ; Thomas, Eric J. ; Puopolo, Ann Louise ; Yoon, Catherine ; Brennan, Troyen A. ; Studdert, David M. / Missed and delayed diagnoses in the ambulatory setting : A study of closed malpractice claims. In: Annals of internal medicine. 2006 ; Vol. 145, No. 7. pp. 488-496.
@article{96b399ebf55048738601f33791ce0ade,
title = "Missed and delayed diagnoses in the ambulatory setting: A study of closed malpractice claims",
abstract = "Background: Although missed and delayed diagnoses have become an important patient safety concern, they remain largely unstudied, especially in the outpatient setting. Objective: To develop a framework for investigating missed and delayed diagnoses, advance understanding of their causes, and identify opportunities for prevention. Design: Retrospective review of 307 closed malpractice claims in which patients alleged a missed or delayed diagnosis in the ambulatory setting. Setting: 4 malpractice insurance companies. Measurements: Diagnostic errors associated with adverse outcomes for patients, process breakdowns, and contributing factors. Results: A total of 181 claims (59{\%}) involved diagnostic errors that harmed patients. Fifty-nine percent (106 of 181) of these errors were associated with serious harm, and 30{\%} (55 of 181) resulted in death. For 59{\%} (106 of 181) of the errors, cancer was the diagnosis involved, chiefly breast (44 claims [24{\%}]) and colorectal (13 claims [7{\%}]) cancer. The most common breakdowns in the diagnostic process were failure to order an appropriate diagnostic test (100 of 181 [55{\%}]), failure to create a proper follow-up plan (81 of 181 [45{\%}]), failure to obtain an adequate history or perform an adequate physical examination (76 of 181 [42{\%}]), and incorrect interpretation of diagnostic tests (67 of 181 [37{\%}]). The leading factors that contributed to the errors were failures in judgment (143 of 181 [79{\%}]), vigilance or memory (106 of 181 [59{\%}]), knowledge (86 of 181 [48{\%}]), patient-related factors (84 of 181 [46{\%}]), and handoffs (36 of 181 [20{\%}]). The median number of process breakdowns and contributing factors per error was 3 for both (interquartile range, 2 to 4). Limitations: Reviewers were not blinded to the litigation outcomes, and the reliability of the error determination was moderate. Conclusions: Diagnostic errors that harm patients are typically the result of multiple breakdowns and individual and system factors. Awareness of the most common types of breakdowns and factors could help efforts to identify and prioritize strategies to prevent diagnostic errors.",
author = "Gandhi, {Tejal K.} and Allen Kachalia and Thomas, {Eric J.} and Puopolo, {Ann Louise} and Catherine Yoon and Brennan, {Troyen A.} and Studdert, {David M.}",
year = "2006",
month = "10",
day = "3",
doi = "10.7326/0003-4819-145-7-200610030-00006",
language = "English (US)",
volume = "145",
pages = "488--496",
journal = "Annals of Internal Medicine",
issn = "0003-4819",
publisher = "American College of Physicians",
number = "7",

}

TY - JOUR

T1 - Missed and delayed diagnoses in the ambulatory setting

T2 - A study of closed malpractice claims

AU - Gandhi, Tejal K.

AU - Kachalia, Allen

AU - Thomas, Eric J.

AU - Puopolo, Ann Louise

AU - Yoon, Catherine

AU - Brennan, Troyen A.

AU - Studdert, David M.

PY - 2006/10/3

Y1 - 2006/10/3

N2 - Background: Although missed and delayed diagnoses have become an important patient safety concern, they remain largely unstudied, especially in the outpatient setting. Objective: To develop a framework for investigating missed and delayed diagnoses, advance understanding of their causes, and identify opportunities for prevention. Design: Retrospective review of 307 closed malpractice claims in which patients alleged a missed or delayed diagnosis in the ambulatory setting. Setting: 4 malpractice insurance companies. Measurements: Diagnostic errors associated with adverse outcomes for patients, process breakdowns, and contributing factors. Results: A total of 181 claims (59%) involved diagnostic errors that harmed patients. Fifty-nine percent (106 of 181) of these errors were associated with serious harm, and 30% (55 of 181) resulted in death. For 59% (106 of 181) of the errors, cancer was the diagnosis involved, chiefly breast (44 claims [24%]) and colorectal (13 claims [7%]) cancer. The most common breakdowns in the diagnostic process were failure to order an appropriate diagnostic test (100 of 181 [55%]), failure to create a proper follow-up plan (81 of 181 [45%]), failure to obtain an adequate history or perform an adequate physical examination (76 of 181 [42%]), and incorrect interpretation of diagnostic tests (67 of 181 [37%]). The leading factors that contributed to the errors were failures in judgment (143 of 181 [79%]), vigilance or memory (106 of 181 [59%]), knowledge (86 of 181 [48%]), patient-related factors (84 of 181 [46%]), and handoffs (36 of 181 [20%]). The median number of process breakdowns and contributing factors per error was 3 for both (interquartile range, 2 to 4). Limitations: Reviewers were not blinded to the litigation outcomes, and the reliability of the error determination was moderate. Conclusions: Diagnostic errors that harm patients are typically the result of multiple breakdowns and individual and system factors. Awareness of the most common types of breakdowns and factors could help efforts to identify and prioritize strategies to prevent diagnostic errors.

AB - Background: Although missed and delayed diagnoses have become an important patient safety concern, they remain largely unstudied, especially in the outpatient setting. Objective: To develop a framework for investigating missed and delayed diagnoses, advance understanding of their causes, and identify opportunities for prevention. Design: Retrospective review of 307 closed malpractice claims in which patients alleged a missed or delayed diagnosis in the ambulatory setting. Setting: 4 malpractice insurance companies. Measurements: Diagnostic errors associated with adverse outcomes for patients, process breakdowns, and contributing factors. Results: A total of 181 claims (59%) involved diagnostic errors that harmed patients. Fifty-nine percent (106 of 181) of these errors were associated with serious harm, and 30% (55 of 181) resulted in death. For 59% (106 of 181) of the errors, cancer was the diagnosis involved, chiefly breast (44 claims [24%]) and colorectal (13 claims [7%]) cancer. The most common breakdowns in the diagnostic process were failure to order an appropriate diagnostic test (100 of 181 [55%]), failure to create a proper follow-up plan (81 of 181 [45%]), failure to obtain an adequate history or perform an adequate physical examination (76 of 181 [42%]), and incorrect interpretation of diagnostic tests (67 of 181 [37%]). The leading factors that contributed to the errors were failures in judgment (143 of 181 [79%]), vigilance or memory (106 of 181 [59%]), knowledge (86 of 181 [48%]), patient-related factors (84 of 181 [46%]), and handoffs (36 of 181 [20%]). The median number of process breakdowns and contributing factors per error was 3 for both (interquartile range, 2 to 4). Limitations: Reviewers were not blinded to the litigation outcomes, and the reliability of the error determination was moderate. Conclusions: Diagnostic errors that harm patients are typically the result of multiple breakdowns and individual and system factors. Awareness of the most common types of breakdowns and factors could help efforts to identify and prioritize strategies to prevent diagnostic errors.

UR - http://www.scopus.com/inward/record.url?scp=33750140829&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=33750140829&partnerID=8YFLogxK

U2 - 10.7326/0003-4819-145-7-200610030-00006

DO - 10.7326/0003-4819-145-7-200610030-00006

M3 - Article

C2 - 17015866

AN - SCOPUS:33750140829

VL - 145

SP - 488

EP - 496

JO - Annals of Internal Medicine

JF - Annals of Internal Medicine

SN - 0003-4819

IS - 7

ER -