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Cited by 559Clinical Reasoning and Diagnostic SkillsPatient Safety and Medication ErrorsPrimary Care and Health Outcomes

Types and Origins of Diagnostic Errors in Primary Care Settings

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Singh, Hardeep, Giardina, Traber Davis, Meyer, Ashley N. D., Forjuoh, Samuel N., Reis, Michael D., Thomas, Eric J.·2013·JAMA Internal Medicine
DOI 10.1001/jamainternmed.2013.2777PMC PMC3690001
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Abstract

IMPORTANCE: Diagnostic errors are an understudied aspect of ambulatory patient safety. OBJECTIVES: To determine the types of diseases missed and the diagnostic processes involved in cases of confirmed diagnostic errors in primary care settings and to determine whether record reviews could shed light on potential contributory factors to inform future interventions. DESIGN: We reviewed medical records of diagnostic errors detected at 2 sites through electronic health record-based triggers. Triggers were based on patterns of patients' unexpected return visits after an initial primary care index visit. SETTING: A large urban Veterans Affairs facility and a large integrated private health care system. PARTICIPANTS: Our study focused on 190 unique instances of diagnostic errors detected in primary care visits between October 1, 2006, and September 30, 2007. MAIN OUTCOME MEASURES: Through medical record reviews, we collected data on presenting symptoms at the index visit, types of diagnoses missed, process breakdowns, potential contributory factors, and potential for harm from errors. RESULTS: In 190 cases, a total of 68 unique diagnoses were missed. Most missed diagnoses were common conditions in primary care, with pneumonia (6.7%), decompensated congestive heart failure (5.7%), acute renal failure (5.3%), cancer (primary) (5.3%), and urinary tract infection or pyelonephritis (4.8%) being most common. Process breakdowns most frequently involved the patient-practitioner clinical encounter (78.9%) but were also related to referrals (19.5%), patient-related factors (16.3%), follow-up and tracking of diagnostic information (14.7%), and performance and interpretation of diagnostic tests (13.7%). A total of 43.7% of cases involved more than one of these processes. Patient-practitioner encounter breakdowns were primarily related to problems with history-taking (56.3%), examination (47.4%), and/or ordering diagnostic tests for further workup (57.4%). Most errors were associated with potential for moderate to severe harm. CONCLUSIONS AND RELEVANCE: Diagnostic errors identified in our study involved a large variety of common diseases and had significant potential for harm. Most errors were related to process breakdowns in the patient-practitioner clinical encounter. Preventive interventions should target common contributory factors across diagnoses, especially those that involve data gathering and synthesis in the patient-practitioner encounter.

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  • Many contributory data are not easily extracted and are often fragmented in medical records or facility data, leaving important human and contextual information unconsidered when measuring diagnostic errors.

    “However, many of the contributory data are not easily extracted and are often fragmented in medical records or facility data, leaving important human and contextual information unconsidered when measuring diagnostic errors [356].”

    From Toward Safer Diagnoses: A SEIPS-Based Narrative Review of Diagnostic Errors (2026) · cites this paper as [356]

    The Discussion (page not provided) says the retrospective study lacked practitioner debriefing, which could have supplied additional useful data. That supports the possibility of missing contextual information, but the paper does not say contributory data are difficult to extract or fragmented across medical records or facility data. (LLM, conf=0.83)

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Research works printed but not linked: 30

  1. [1]Bhasale A The wrong diagnosis: identifying causes of potentially adverse events in general practice using incident monitoring Fam Pract 1998 15 308 318 9792345
  2. [2]Bhasale AL Miller GC Reid SE Britt HC Analysing potential harm in Australian general practice: an incident-monitoring study Med J Aust 1998 169 73 76 9700340
  3. [3]Dovey SM Meyers DS Phillips RL Jr A preliminary taxonomy of medical errors in family practice Qual Saf Health Care 2002 11 233 238 12486987 PMC1743626
  4. [4]Dovey SM Phillips RL Green LA Fryer GE Consequences of medical errors observed by family physicians Am Fam Physician 2003 67 915 12643351
  5. [5]Elder NC Dovey SM Classification of medical errors and preventable adverse events in primary care: a synthesis of the literature J Fam Pract 2002 51 927 932 12485545
  6. [6]Ely JW Levinson W Elder NC Mainous AG III Vinson DC Perceived causes of family physicians' errors J Fam Pract 1995 40 337 344 7699346
  7. [8]Bishop TF Ryan AK Casalino LP Paid malpractice claims for adverse events in inpatient and outpatient settings JAMA 2011 305 2427 2431 21673294
  8. [9]Gandhi TK Fumbled handoffs: one dropped ball after another Ann Intern Med 2005 142 352 358 15738454
  9. [11]Phillips R Jr Bartholomew LA Dovey SM Fryer GE Jr Miyoshi TJ Green LA Learning from malpractice claims about negligent, adverse events in primary care in the United States Qual Saf Health Care 2004 13 121 126 15069219 PMC1743812
  10. [12]Sandars J Esmail A The frequency and nature of medical error in primary care: understanding the diversity across studies Fam Pract 2003 20 231 236 12738689
  11. [13]Singh H Weingart S Diagnostic Errors in Ambulatory Care: Dimensions and Preventive Strategies Adv Health Sci Educ Theory Pract 2009 14 Suppl 1 57 61 19669923 PMC3643195
  12. [14]Singh H Graber M Reducing diagnostic error through medical home-based primary care reform JAMA 2010 304 463 464 20664048 PMC3120138
  13. [15]Schiff GD Hasan O Kim S Diagnostic Error in Medicine: Analysis of 583 Physician-Reported Errors Arch Intern Med 2009 169 1881 1887 19901140
  14. [16]Ely JW Kaldjian LC D'Alessandro DM Diagnostic Errors in Primary Care: Lessons Learned J Am Board Fam Pract 2012 25 87 97 22218629
  15. [17]Sarkar U Bonacum D Strull W Challenges of making a diagnosis in the outpatient setting: a multi-site survey of primary care physicians BMJ Qual Saf 2012 21 641 648 PMC3680371 22626738
  16. [18]Lorincz CY Drazen E Sokol PE Research in Ambulatory Patient Safety 2000–2010: A 10-year review American Medical Association 2011
  17. [19]Wynia MK Classen DC Improving Ambulatory Patient Safety JAMA 2011 306 2504 2505 22166611
  18. [21]Singh H Daci K Petersen L Missed opportunities to initiate endoscopic evaluation for colorectal cancer diagnosis Am J Gastroenterol 2009 104 2543 2554 19550418 PMC2758321
  19. [22]Singh H Hirani K Kadiyala H Characteristics and predictors of missed opportunities in lung cancer diagnosis: an electronic health record-based study J Clin Oncol 2010 28 3307 3315 20530272 PMC2903328
  20. [23]Singh H Giardina TD Petersen LA Exploring situational awareness in diagnostic errors in primary care BMJ Qual Saf 2012 21 30 38 PMC3692739 21890757
  21. [25]Singh H Thomas EJ Wilson L Errors of diagnosis in pediatric practice: a multisite survey Pediatrics 2010 126 70 79 20566604 PMC2921702
  22. [26]Singh H Thomas E Khan MM Petersen L Identifying diagnostic errors in primary care using an electronic screening algorithm Arch Intern Med 2007 167 302 308 17296888
  23. [27]Singh H Sethi S Raber M Petersen LA Errors in cancer diagnosis: current understanding and future directions J Clin Oncol 2007 25 5009 5018 17971601
  24. [28]Singh H Graber ML Kissam SM System-related interventions to reduce diagnostic errors: a narrative review BMJ Qual Saf 2012 21 160 170 PMC3677060 22129930
  25. [31]Kostopoulou O Delaney BC Munro CW Diagnostic difficulty and error in primary care--a systematic review Fam Pract 2008 25 400 413 18842618
  26. [33]Zwaan L de BM Wagner C Patient record review of the incidence, consequences, and causes of diagnostic adverse events Arch Intern Med 2010 170 1015 1021 20585065
  27. [34]Paley L Zornitzki T Cohen J Friedman J Kozak N Schattner A Utility of clinical examination in the diagnosis of emergency department patients admitted to the department of medicine of an academic hospital Arch Intern Med 2011 171 1394 1396 21824956
  28. [35]Schiff GD Bates DW Can Electronic Clinical Documentation Help Prevent Diagnostic Errors? N Engl J Med 2010 362 1066 1069 20335582
  29. [37]Graber ML Kissam S Payne VL Cognitive interventions to reduce diagnostic error: a narrative review BMJ Quality & Safety 2012 21 535 557 22543420
  30. [39]Zwaan L Thijs A Wagner C van der WG Timmermans DR Relating faults in diagnostic reasoning with diagnostic errors and patient harm Acad Med 2012 87 149 156 22189886

Cited by

Sorted by citations

Authors
Singh, H., Giardina, T. D., Meyer, A. N. D., Forjuoh, S. N., Reis, M. D., & Thomas, E. J.
Affiliations
  • Michael E. DeBakey VA Medical Center (US)
  • Texas A&M Health Science Center (US)
  • Memorial Hermann (US)
ORCID
Venue
JAMA Internal Medicine
Publisher
American Medical Association (AMA)
Published
2013-03-25
Volume
173
Issue
6
Pages
418
ISSN
2168-6106 (ISSN-L)
DOI
10.1001/jamainternmed.2013.2777
PMC
PMC3690001
OpenAlex
W2029907219
Cited by
559
References
6
Citations by year
2026: 36 · 2025: 52 · 2024: 38 · 2023: 48 · 2022: 45 · 2021: 51 · 2020: 54 · 2019: 43 · 2018: 39 · 2017: 41 · 2016: 25 · 2015: 32 · 2014: 25 · 2013: 28
FWCI
31.68
Type
journal article
Language
en
Open access
Locations
  • JAMA Internal Medicine (publishedVersion)
  • PubMed (publishedVersion)
  • Europe PMC (PubMed Central) (acceptedVersion)
  • PubMed Central (acceptedVersion)
Funders
  • Agency for Healthcare Research and Quality (R18 HS17244-02)
  • National Cancer Institute (K23CA125585)
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 › Health Professions › General Health Professions › Primary Care and Health Outcomes
Keywords
diagnostic errors, primary care, patient safety, missed diagnosis, medical history, physical examination, diagnostic test ordering, pneumonia, congestive heart failure, acute kidney injury, cancer, urinary tract infection, contributing factors
MeSH terms
Aged, Ambulatory Care, Ambulatory Care Information Systems, Diagnosis, Diagnostic Errors, Disease, Female, Humans, Male, Middle Aged, Primary Health Care, Quality of Health Care, United States, United States Department of Veterans Affairs, Outcome Assessment, Health Care, Health Care Surveys, Electronic Health Records

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