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Cited by 626Clinical Reasoning and Diagnostic SkillsPatient Safety and Medication ErrorsMedical Malpractice and Liability Issues

The incidence of diagnostic error in medicine

Open access
Graber, Mark L·2013·BMJ Quality & Safety
DOI 10.1136/bmjqs-2012-001615PMC PMC3786666
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Abstract

A wide variety of research studies suggest that breakdowns in the diagnostic process result in a staggering toll of harm and patient deaths. These include autopsy studies, case reviews, surveys of patient and physicians, voluntary reporting systems, using standardised patients, second reviews, diagnostic testing audits and closed claims reviews. Although these different approaches provide important information and unique insights regarding diagnostic errors, each has limitations and none is well suited to establishing the incidence of diagnostic error in actual practice, or the aggregate rate of error and harm. We argue that being able to measure the incidence of diagnostic error is essential to enable research studies on diagnostic error, and to initiate quality improvement projects aimed at reducing the risk of error and harm. Three approaches appear most promising in this regard: (1) using ‘trigger tools’ to identify from electronic health records cases at high risk for diagnostic error; (2) using standardised patients (secret shoppers) to study the rate of error in practice; (3) encouraging both patients and physicians to voluntarily report errors they encounter, and facilitating this process.

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  • Diagnostic errors are as high as 10-15%, impacting patient health and system costs.

    “Estimates evaluate diagnostic errors as high as 10-15%, impacting patient health and system costs [1][2][3] .”

    From Enhancing human-AI collaboration: The case of colonoscopy (2024) · cites this paper as [1]

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Research works printed but not linked: 54

  1. [1]Hastie T Tibshirani R Friedman J The elements of statistical learning. 2nd edn, Springer, 2009
  2. [2]Graber M Wachter R Cassel C Bringing diagnosis into the quality and safety equations. JAMA 2012; 308: 1211– 12 23011708
  3. [3]Graber ML Diagnostic error in medicine: a case of neglect. Jt Comm J Qual Patient Saf 2004; 31: 112– 19 15791770
  4. [4]Wachter R Why diagnostic errors don't get any respect—and what can be done about them. Health Affairs 2010; 29: 1605– 10 20820015
  5. [5]Pronovost PJ Colantuoni E Measuring preventable harm. JAMA 2009; 301: 1273– 75 19318654
  6. [6]Berner E Graber M Overconfidence as a cause of diagnostic error in medicine. Am J Med 2008; 121(5 Suppl Diagnostic Error in Medicine): S2– 23 18440350
  7. [7]Elstein A Clinical reasoning in medicine. In: Higgs J, ed. Clinical reasoning in the health professions. Oxford, England: Butterworth-Heinemann Ltd, 1995; 49– 59
  8. [9]Sonderegger-Iseli K Burger S Muntwyler J Diagnostic errors in three medical eras: a necropsy study. Lancet 2000; 355: 2027– 31 10885353
  9. [10]Blendon RJ DesRoches CM Brodie M Views of practicing physicians and the public on medical errors. N Engl J Med 2002; 347: 1933– 40 12477944
  10. [11]Singh H Thomas E Wilson L Errors of diagnosis in pediatric practice: a multisite survey. Pediatrics 2010; 126: 70– 9 20566604 PMC2921702
  11. [12]Peabody JW Luck J Jain S Assessing the accuracy of administrative data in health information systems. Med Care 2004; 42: 1066– 72 15586833
  12. [13]Beam CA Layde PM Sullivan DC Variability in the interpretation of screening mammograms by US radiologists. Findings from a national sample. Arch Intern Med 1996; 156: 209– 13 8546556
  13. [14]Raab SS Variability of practice in anatomic pathology and its effect on patient outcomes. Semin Diagn Pathol 2005; 22: 177– 85 16639996
  14. [15]Schiff GD Hasan O Kim S Diagnostic error in medicine—analysis of 583 physician-reported errors. Arch Int Med 2009; 169: 1881– 87 19901140
  15. [17]Charlton I Jones K Bain J Delay in diagnosis of childhood asthma and its influence on respiratory consultation rates. Arch Dis Child 1991; 66: 633– 35 2039256 PMC1792928
  16. [18]Kowalski R Claasen J Kreiter K Initial misdiagnosis and outcome after subarrachnoid hemorrhage. JAMA 2004; 291: 866– 69 14970066
  17. [20]Sevdalis N Jacklin R Arora S Diagnostic error in a national incident reporting system in the UK. J Eval Clin Pract 2010; 16: 1276– 78 20727061
  18. [24]Gehring K Schwappach D Battaglila M Frequency and harm associated with primary care safety incidents. Am J Manag Care 2012; 18: e323– e37 23009331
  19. [25]Weiner S Schwartz A Weaver F Contextual errors and failures in indivdualizing patient care. Ann Int Med 2010; 153: 69– 75 20643988
  20. [26]Schwartz A Weiner S Weaver F Uncharted territory: measuring costs of diagnostic errors outside the medical record. BMJ Qual Saf 2012 22773889
  21. [27]Kostopoulou O Oudhoff J Nath R Predictors of diagnostic accuracy and safe management in difficult diagnostic problems in family medicine. Med Decis Making 2008; 28: 668– 80 18556634
  22. [28]Fitzgerald R Error in radiology. Clin Radiol 2001; 56: 938– 46 11795921
  23. [29]Foucar E Error in anatomic pathology. Am J Clin Pathol 2001; 116(Suppl Diagnostic Error in Medicine): S34– 46 11993701
  24. [30]Westra WH Kronz JD Eisele DW The impact of second opinion surgical pathology on the practice of head and neck surgery: a decade experience at a large referral hospital. Head Neck 2002; 24: 684– 93 12112543
  25. [31]Raab SS GD Quality in Cancer Diagnosis. CA Cancer J Clin 2010; 60: 27
  26. [35]Tehrani A Lee H Mathews S 25-year summary of US malpractice claims for diagnostic errors 1986–2010; An analysis from the National Practitioner Data Bank. BMJ Qual Saf 2013 23610443
  27. [36]Newman-Toker D Robinson K Edlow J Frontline misdiagnosis of cerebrovascular events in the era of modern neuro-imaging: a systematic review. Ann Neurol 2008; 64(Suppl 12 Diagnostic Error in Medicine): S17– 18
  28. [37]Kostopoulou O Delaney BC Munro CW Diagnostic difficulty and error in primary care—a systematic review. Fam Pract 2008; 25: 400– 13 18842618
  29. [38]Singh H Daci K Petersen LA Missed opportunities to initiate endoscopic evaluation for colorectal cancer diagnosis. Am J Gastroenterol 2009; 104: 2543– 54 19550418 PMC2758321
  30. [39]Singh H Hirani K Kadiyala H Characteristics and predictors of missed opportunities in lung cancer diagnosis. J Clinical Oncology 2010; 28: 3307– 15 PMC2903328 20530272
  31. [40]Kostopoulou O Delaney B Confidential reporting of patient safety events in primary care: results from a multilevel classification of cognitive and system factors. Qual Saf Health Care 2007; 16: 95– 100 17403753 PMC2653163
  32. [41]Graber ML Taking steps towards a safer future: measures to promote timely and accurate medical diagnosis. Am J Med 2008; 121(Suppl 5 Diagnostic Error in Medicine): S43– 6 18440355
  33. [42]Tsang C Majeed A Avlin P Routinely recorded patient safety events in primary care: a literature review. Fam Pract 2012; 29: 8– 15 21878467
  34. [44]Resar RK Rozich JD Classen D Methodology and rationale for the measurement of harm with trigger tools. Qual Saf Health Care 2003; 12(Suppl 2 Diagnostic Error in Medicine): ii39– 45 14645894 PMC1765771
  35. [45]Classen D Resar R Griffin F Global Trigger Tool shows that adverse events in hospitals may be ten times greater than previously measured. Health Affairs 2011; 30: 581– 89 21471476
  36. [46]Schildmeijer K Nilsson L Arestedt K Assessment of adverse events in medical care: lack of consistency between experienced teams using the global trigger tool. BMJ Qual Saf 2012; 31: 307– 14 22362917
  37. [47]Singh H Thomas EJ Khan MM Identifying diagnostic errors in primary care using an electronic screening algorithm. Arch Intern Med 2007; 167: 302– 8 17296888
  38. [49]Singh H Traber D Meyer A Types and origins of diagnostic errors in primary care settings. JAMA Internal Med 2013 PMC3690001 23440149
  39. [52]Schiff G Finding and fixing diagnosis errors: can triggers help? BMJ Qual Saf 2012; 21: 89– 92 22129932
  40. [53]Burroughs TE Waterman AD Gallagher TH Patient concerns about medical errors in emergency departments. Acad Emerg Med 2005; 23: 57– 64 15635139
  41. [54]Schiff GD Minimizing diagnostic error: the importance of follow-up and feedback. Am J Med 2008; 121(5 Suppl Diagnostic Error in Medicine): S38– 42 18440354
  42. [55]Graber ML Reducing diagnostic error in medicine—there's a job for everyone. NPSF Focus Patient Saf 2009; 12: 6– 7
  43. [56]Shrier I Green S Solin J Knowledge of and attitude toward patient confidentiality within three family medicine teaching units. Acad Med 1998; 73: 710– 12 9653413
  44. [57]Weingart S Pagovich O DZ S What can hospitalized patients tell us about adverse events? Learning from patient-reported incidents. J Gen Intern Med 2005; 20: 7 16117751 PMC1490203
  45. [59]Hasegawa T Fujita S Seto K Patient identification and reporting of unsafe events at six hospitals in Japan. Jt Comm J Qual Patient Saf 2011; 37: 502– 08 22132662
  46. [60]Ohrn A Elfstrom J Liedgren C Reporting of sentinel events in Swedish hospitals: a comparison of severe adverse events reported by patients and providers. Jt Comm J Qual Patient Saf 2011; 37: 495– 501 22132661
  47. [61]Tierney WM Adverse outpatient drug events – a problem and an opportunity. N Engl J Med 2003; 348: 1587– 89 12700379
  48. [62]Phillips RL Jr. Bartholomew LA Dovey SM Learning from malpractice claims about negligent, adverse events in primary care in the United States. Qual Saf Health Care 2004; 13: 121– 26 15069219 PMC1743812
  49. [63]Trowbridge R Salvador O Addressing diagnostic errors: an institutional approach. Focus Patient Saf Newsletter National Patient Saf Found 2010; 13: 1– 5
  50. [64]Leape L Berwick D Bates D Counting deaths from medical errors. JAMA 2002; 288: 240512435249
  51. [65]Winters B Custer J Galvagno S Diagnostic errors in the intensive care unit: a systematic review of autopsy studies. BMJ Qual Saf 2012; 21: 894– 902 22822241
  52. [66]Shojania K Deaths due to medical error: jumbo jets or just small propeller planes? BMJ Qual Saf 2012; 21: 709– 12 22831904
  53. [67]Zwaan L de Bruijne M Wagner C Patient record review of the incidence, consequences, and causes of diagnostic adverse events. Arch Intern Med 2010; 170: 1015– 21 20585065
  54. [68]Lorincz C Drazen E Sokol P Research in ambulatory patient safety 2000–2010: a 10-year review. Chicago, IL: American Medical Association, 2011

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Authors
Graber, M. L.
Affiliations
RTI International (US)
Corresponding author
Graber, Mark L
ORCID
Graber, Mark L
Venue
BMJ Quality & Safety
Publisher
BMJ
Published
2013-06-15
Volume
22
Issue
Suppl 2
Pages
ii21-ii27
ISSN
  • 1475-3898 (ISSN-L)
  • 2044-5415
  • 2044-5423
DOI
10.1136/bmjqs-2012-001615
PMC
PMC3786666
OpenAlex
W2132131059
Cited by
626
References
6
Citations by year
2026: 35 · 2025: 37 · 2024: 49 · 2023: 67 · 2022: 52 · 2021: 59 · 2020: 88 · 2019: 58 · 2018: 59 · 2017: 38 · 2016: 26 · 2015: 34 · 2014: 16 · 2013: 8
FWCI
22.22
Type
journal article
Language
en
Open access
Licence
cc-by-nc
Locations
  • BMJ Quality & Safety (publishedVersion, cc-by-nc)
  • Europe PMC (PubMed Central) (publishedVersion, other-oa)
  • PubMed Central (publishedVersion, cc-by-nc)
  • PubMed (publishedVersion)
  • HighWire Press Open Archive (submittedVersion)
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 › Pharmacy › Medical Malpractice and Liability Issues
Keywords
diagnostic errors, patient harm, trigger tool, standardized patients, autopsy studies, electronic health records, quality improvement
MeSH terms
Autopsy, Diagnostic Errors, Malpractice, Research Design, Patient Simulation, Clinical Laboratory Techniques, Disclosure, Clinical Audit, Patient Safety

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