Diagnostic errors lead to the majority of US malpractice claims and have public health consequences because of patient harm.
Cognitive biases present in clinicians can contribute to diagnostic errors.
Maintenance of certification programs can increase the quality of patient care while enabling clinicians to reduce diagnostic errors and avoid malpractice suits.
Cases of medical misdiagnosis—not surgical mistakes or medication overdoses—account for the largest proportion of US malpractice claims. They also contribute to the most severe patient harm and thus have a significant impact on patient safety and public health.
According to a study published in BMJ Quality and Safety, diagnosis-related payouts amounted to $38.8 billion between 1986 and 2010.
But help in reducing diagnostic errors, and preventing malpractice suits, is available—in the form of education.
Define diagnostic errors
“This is more evidence that diagnostic errors could easily be the biggest patient safety and medical malpractice problem in the United States,” said David E. Newman-Toker, MD, PhD, lead author of the BMJ Quality and Safety study in a press release.
"There’s a lot more harm associated with diagnostic errors than we imagined. "
— David E. Newman-Toker, MD, PhD
Diagnostic errors are defined as diagnoses that are wrong, delayed, or missed.
These errors are often detected by a later finding or definitive test. Harm to patients results from failure to receive treatment, or experiencing a delay in treatment, for their current illness, because the working diagnosis is wrong or unknown. Some patients may receive treatment for a condition they don’t actually have.
Diagnostic errors lead to death or disability nearly twice as often as other types of errors, according to the BMJ Quality and Safety study. Diagnostic errors were more likely to occur in outpatient care settings than in inpatient care (68.8% vs 31.2%).
However, inpatient diagnostic errors were more likely to be fatal (48.4% vs 36.9%). The study authors found that most diagnostic errors were missed diagnoses, not delayed or wrong ones.
Diagnostic error causes
There has been extensive research (informed by the field of cognitive psychology) conducted on why diagnostic errors happen. At the individual physician level, cognitive biases are the main culprit in diagnostic errors.
It is common for clinicians to use heuristics (“rules of thumb”) to make a preliminary diagnosis, but if this is applied inappropriately, a cognitive bias can result. Here are examples:
Availability heuristic: Diagnosis of a current patient that’s biased by experiences with previous patients
Anchoring heuristic: Diagnosing a patient by sticking to an initial diagnosis despite the presence of subsequent information to the contrary
Framing effects: Diagnosis of a patient biased by subtle cues and ancillary information
Blind obedience: Excessive reliance on a test result or expert opinion for a diagnosis
While cognitive biases may contribute to many diagnostic errors, other issues can lead to missed or delayed diagnoses, such as poor communication between healthcare providers.
Prevent diagnostic errors
To avoid preventable diagnostic errors, healthcare providers should be seeking to constantly challenge their diagnosis.
In a Medpage Today article, Dana Siegal, RN, says clinicians should take a “diagnostic timeout” and ask themselves, “What else could this be? Have I truly explored all the other possibilities that seem relevant in this scenario and, more importantly, what doesn't fit?” She advises physicians to be sure to dis-confirm their diagnosis as well.
Diagnostic error prevention is highly dependent on assuring that all healthcare providers involved in patient care receive adequate education and training.
In addition to obtaining state medical licenses, the majority of US doctors are also certified by privately run boards. These boards certify that physicians excel in their fields, such as pathology or pediatrics.
Traditionally, boards have required physicians to take exams every 10 years to maintain certification.
In recent years, many boards have made physicians enroll in Maintenance of Certification (MOC) programs in between the exam years to show that they’re actively engaged in learning and improving themselves. These programs have been controversial, as many doctors find them costly and irrelevant.
Despite this controversy, positive associations have been reported between MOC programs and improved clinical outcomes, better clinical processes, and cost savings for participating physicians.
A study of 42,000 physicians found that physicians who were board-certified in emergency medicine— which requires participation in MOC programs—were less likely to miss a diagnosis of acute myocardial infarction in the emergency department compared with non-certified physicians.
This study highlights the importance of continuing education in enabling physicians to reach the correct diagnosis, offer higher quality of care to patients, and avoid malpractice lawsuits associated with diagnostic errors.
What this means for you
Diagnostic errors have a significant negative impact on the quality of patient care, and account for more US malpractice claims than surgical mistakes and medication errors. While these errors can be triggered by cognitive biases such as anchoring on a diagnosis even when contradictory evidence is found, it’s critical that clinicians attempt to challenge their diagnosis as well as communicating openly with colleagues. Stay up to date with your certification programs, as evidence suggests they can decrease the frequency of diagnostic errors, resulting in better patient care and fewer malpractice lawsuits.