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Cited by 1,549Clinical Reasoning and Diagnostic SkillsPatient Safety and Medication ErrorsAutopsy Techniques and Outcomes

Diagnostic error in internal medicine

Graber, Mark L., Franklin, Nancy, Gordon, Ruthanna·2005·Archives of Internal Medicine
DOI 10.1001/archinte.165.13.1493
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Abstract

BACKGROUND: The goal of this study was to determine the relative contribution of system-related and cognitive components to diagnostic error and to develop a comprehensive working taxonomy. METHODS: One hundred cases of diagnostic error involving internists were identified through autopsy discrepancies, quality assurance activities, and voluntary reports. Each case was evaluated to identify system-related and cognitive factors underlying error using record reviews and, if possible, provider interviews. RESULTS: Ninety cases involved injury, including 33 deaths. The underlying contributions to error fell into 3 natural categories: "no fault," system-related, and cognitive. Seven cases reflected no-fault errors alone. In the remaining 93 cases, we identified 548 different system-related or cognitive factors (5.9 per case). System-related factors contributed to the diagnostic error in 65% of the cases and cognitive factors in 74%. The most common system-related factors involved problems with policies and procedures, inefficient processes, teamwork, and communication. The most common cognitive problems involved faulty synthesis. Premature closure, ie, the failure to continue considering reasonable alternatives after an initial diagnosis was reached, was the single most common cause. Other common causes included faulty context generation, misjudging the salience of findings, faulty perception, and errors arising from the use of heuristics. Faulty or inadequate knowledge was uncommon. CONCLUSIONS: Diagnostic error is commonly multifactorial in origin, typically involving both system-related and cognitive factors. The results identify the dominant problems that should be targeted for additional research and early reduction; they also further the development of a comprehensive taxonomy for classifying diagnostic errors.

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  • Although many contributors to diagnostic error have been identified, they are typically discussed in isolation rather than as part of an interacting system.

    “Although many contributors to diagnostic error have been identified in the previous literature, they are typically discussed in isolation rather than as part of an interacting system [25,33].”

    From Toward Safer Diagnoses: A SEIPS-Based Narrative Review of Diagnostic Errors (2026) · cites this paper as [33]

  • Previous exploratory studies in patient safety have been able to shed powerful light on contributory factors with a similar sample size.

    “Previous exploratory studies in patient safety have been able to shed powerful light on contributory factors with a similar sample size.44”

    From An analysis of electronic health record-related patient safety concerns (2014) · cites this paper as [44]

  • Missed laboratory results or delayed recognition of results creates a significant potential for outpatient diagnostic errors, adverse events, and liability claims.

    “missed laboratory results or delayed recognition of results leads to a significant potential for outpatient diagnostic errors, adverse events and liability claims.”

    From Notification of Abnormal Lab Test Results in an Electronic Medical Record: Do Any Safety Concerns Remain? (2010) · cites this paper as [14]

  • Diagnostic errors are often attributed to cognitive and/or systems-related factors.

    “Although diagnostic errors may occur when signs of a disease are atypical or absent, diagnostic errors are often attributed to cognitive (e.g., faulty clinical reasoning) and/or systems-related factors (e.g., inefficient processes and poor communication7,9–21).”

    From Reducing Diagnostic Errors through Effective Communication: Harnessing the Power of Information Technology (2008) · cites this paper as [7]

  • Evidence suggests that the most common medical error results from inadequate clinical reasoning.

    “Evidence suggests that the most common medical error results from inadequate clinical reasoning [3, 9].”

    From The virtual patient as a learning tool: a mixed quantitative qualitative study (2018) · cites this paper as [3]

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Authors
Graber, M. L., Franklin, N., & Gordon, R.
Affiliations
Northport VA Medical Center (US)
ORCID
Graber, Mark L.
Venue
Archives of Internal Medicine
Publisher
American Medical Association (AMA)
Published
2005-07-11
Volume
165
Issue
13
Pages
1493
ISSN
0003-9926 (ISSN-L)
DOI
10.1001/archinte.165.13.1493
OpenAlex
W2141222241
Cited by
1,549
References
45
Citations by year
2026: 109 · 2025: 74 · 2024: 92 · 2023: 112 · 2022: 115 · 2021: 130 · 2020: 82 · 2019: 92 · 2018: 77 · 2017: 78 · 2016: 62 · 2015: 83 · 2014: 71 · 2013: 83 · 2012: 67
FWCI
16.30
Type
journal article
Language
en
Open access
closed
Locations
  • Archives of Internal Medicine (publishedVersion)
  • PubMed (publishedVersion)
Topics
  • Health Sciences › Medicine › Family Practice › Clinical Reasoning and Diagnostic Skills
  • Health Sciences › Health Professions › Emergency Medical Services › Patient Safety and Medication Errors
  • Health Sciences › Medicine › Radiology, Nuclear Medicine and Imaging › Autopsy Techniques and Outcomes
Keywords
diagnostic errors, internal medicine, cognitive factors, premature closure, heuristics, teamwork and communication, medical errors
MeSH terms
Australia, Diagnostic Errors, Humans, Internal Medicine, Interviews as Topic, Practice Patterns, Physicians', Quality Assurance, Health Care, Cognitive Science

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