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Cited by 43Clinical Reasoning and Diagnostic SkillsPatient Safety and Medication ErrorsHospital Admissions and Outcomes

What Contributes to Diagnostic Error or Delay? A Qualitative Exploration Across Diverse Acute Care Settings in the United States

Open access
Barwise, Amelia, Leppin, Aaron, Dong, Yue, Huang, Chanyan, Pinevich, Yuliya, Herasevich, Svetlana, Soleimani, Jalal, Gajic, Ognjen +2 more·2021·Journal of Patient Safety
DOI 10.1097/pts.0000000000000817PMC PMC8195035
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Abstract

Objectives: Diagnostic error and delay is a prevalent and impactful problem. This study was part of a mixed-methods approach to understand the organizational, clinician, and patient factors contributing to diagnostic error and delay among acutely ill patients within a health system, as well as recommendations for the development of tailored, targeted, feasible, and effective interventions. Methods: We did a multisite qualitative study using focus group methodology to explore the perspectives of key clinician stakeholders. We used a conceptual framework that characterized diagnostic error and delay as occurring within 1 of 3 stages of the patient’s diagnostic journey—critical information gathering, synthesis of key information, and decision making and communication. We developed our moderator guide based on the sociotechnical frameworks previously described by Holden and Singh for understanding noncognitive factors that lead to diagnostic error and delay. Deidentified focus group transcripts were coded in triplicate and to consensus over a series of meetings. A final coded data set was then uploaded into NVivo software. The data were then analyzed to generate overarching themes and categories. Results: We recruited a total of 64 participants across 4 sites from emergency departments, hospital floor, and intensive care unit settings into 11 focus groups. Clinicians perceive that diverse organizational, communication and coordination, individual clinician, and patient factors interact to impede the process of making timely and accurate diagnoses. Conclusions: This study highlights the complex sociotechnical system within which individual clinicians operate and the contributions of systems, processes, and institutional factors to diagnostic error and delay.

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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 [25]

  • Women with breast cancer who had self-examination knowledge were found to be more aware of any abnormalities and sought help from the physician earlier than those without that knowledge.

    “women with breast cancer who had self-examination knowledge were found to be more aware of any abnormalities and sought help from the physician earlier than those without that knowledge [25].”

    From Toward Safer Diagnoses: A SEIPS-Based Narrative Review of Diagnostic Errors (2026) · cites this paper as [25]

  • Patient characteristics, such as health literacy and disease awareness, affect how individuals can articulate their symptoms and understand treatment instructions, which directly impacts the diagnostic process.

    “patient characteristics, such as health literacy and disease awareness, affect how individuals can articulate their symptoms and understand treatment instructions, which directly impacts the diagnostic process [24,25].”

    From Toward Safer Diagnoses: A SEIPS-Based Narrative Review of Diagnostic Errors (2026) · cites this paper as [25]

  • Communication problems during handoffs occur in various environments, particularly frequently during patient transfers from external facilities, where incomplete information is commonly received.

    “Communication problems during handoffs occur in various environments, particularly frequently during patient transfers from external facilities, where incomplete information is commonly received [25].”

    From Toward Safer Diagnoses: A SEIPS-Based Narrative Review of Diagnostic Errors (2026) · cites this paper as [25]

  • This can result in challenges when incorporating diverse opinions among a healthcare team, which are necessary to create a thorough diagnosis, and hinder the opportunity to learn from feedback that enhances mistake prevention and patient care.

    “This can result in challenges when incorporating diverse opinions among a healthcare team, which are necessary to create a thorough diagnosis [25], and hinder the opportunity to learn from feedback that enhances mistake prevention and patient care [256].”

    From Toward Safer Diagnoses: A SEIPS-Based Narrative Review of Diagnostic Errors (2026) · cites this paper as [25]

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Authors
Barwise, A., Leppin, A., Dong, Y., Huang, C., Pinevich, Y., Herasevich, S., Soleimani, J., Gajic, O., Pickering, B., & Kumbamu, A.
Affiliations
  • Division of Pulmonary and Critical Care Medicine
  • Knowledge and Evaluation Research Unit (KER)
  • Department of Anesthesiology and Perioperative Medicine
  • Mayo Clinic (US)
Corresponding author
  • Barwise, Amelia
  • Gajic, Ognjen
ORCID
Venue
Journal of Patient Safety
Publisher
Ovid Technologies (Wolters Kluwer Health)
Published
2021-01-23
Volume
17
Issue
4
Pages
239-248
ISSN
  • 1549-8417 (ISSN-L)
  • 1549-8425
DOI
10.1097/pts.0000000000000817
PMC
PMC8195035
OpenAlex
W3156720228
Cited by
43
References
87
Citations by year
2026: 12 · 2025: 13 · 2024: 6 · 2023: 8 · 2022: 3 · 2021: 1
FWCI
4.83
Type
journal article
Language
en
Open access
Locations
  • Journal of Patient Safety (publishedVersion)
  • PubMed (publishedVersion)
  • PubMed Central (acceptedVersion)
Funders
Agency for Healthcare Research and Quality (R18HS026609)
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 › Emergency Medicine › Hospital Admissions and Outcomes
Keywords
diagnostic errors, delayed diagnosis, acute care, emergency department, intensive care unit, hospital floors, clinician perspectives, organizational factors, communication and coordination, decision-making, patient factors, socio-technical systems, diagnostic journey, patient safety interventions
MeSH terms
Communication, Diagnostic Errors, Humans, United States, Focus Groups, Consensus, Qualitative Research

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