Diagnostic error tops patient safety concerns

Ecri Top10 V2


“It’s remarkable and gratifying. And it’s due time,” says Gordon Schiff, M.D., a leader in the movement to improve diagnosis, upon hearing that a leading health care improvement organization considers diagnostic error the number one patient safety concern in the country.

While Schiff and others at the Society to Improve Diagnosis in Medicine (SIDM) are deeply involved in researching ways to better understand and stem diagnostic error, they also see value in raising general awareness that missed, delayed and incorrect diagnoses can have a profound effect on patients’ health and lives.

The top-10 list, issued annually by ECRI Institute, a non-profit research and risk management firm, is widely anticipated, circulated and discussed in patient safety circles. The list gives visibility to new, evolving and perennial safety problems in patient care and helps organizations recognize, evaluate and prepare to improve them.

Gordon Schiff, MD, spoke at the Diagnostic Error in Medicine
conference in Boston in November 2017.

Schiff notes that where each patient safety concern ranks on the list is less important than the attention brought to many of the highly ranked issues: “They’re all important. And it’s interesting how many items on the list are interconnected with diagnostic error.” He points out that health information technology, number five on the list, plays a role both in supporting clinicians in the diagnostic process and contributing to errors. Other concerns – care coordination, health literacy and patient engagement – are also key to ensuring an accurate diagnosis.

Efforts to lessen the frequency of diagnostic error – estimated by the National Academy of Medicine to affect one in 20 Americans – and the harm it causes have expanded to include the study of how to improve the diagnostic process in general, not just prevent errors.

SIDM and a broad group of stakeholder organizations, the Coalition to Improve Diagnosis, are exploring, for example, how best to teach physicians to think through diagnostic challenges and to incorporate a range of clinicians – plus patients and family members – on the diagnostic team.  

Diagnostic error is expensive

In addition to harming patients, diagnostic error is a prime source of liability claims and financial loss.

new analysis of more than 10,000 closed malpractice claims published earlier this year by Coverys, a Boston-based insurer of health care organizations across the country, found that diagnosis-related failures are the single largest contributor to malpractice claims.

Coverys characterizes its findings as “signals from the past about where vulnerabilities existed and may still be at play.” Among the vulnerabilities: more than half of the claims related to diagnostic harm involved poor clinical decision-making. Although many diagnostic errors stem from typical safety risks – miscommunication, dysfunctions in organizational culture, and lack of care coordination – cognitive mistakes made by individuals who jump to the wrong conclusion or fail to ask for help from colleagues or other means of decision support must also be addressed.   

A new analysis of closed malpractice claims found that diagnosis-related failures are the single largest root cause of claims, resulting in indemnity payments slightly higher than the next five highest categories combined.(Graphic from “Diagnostic Accuracy: Room for Improvement.” Used with permission from Coverys.)


CRICO, which provides medical professional liability insurance for Harvard’s medical institutions, also raised concerns in a 2014 report about the role misdiagnosis plays in patient harm. Most diagnostic failures in the national claims data analyzed by CRICO, occurred in ambulatory care. A 2013 study authored by Schiff and his team at Harvard showed that more than 70% of malpractice claims in primary care were related to allegations of diagnostic errors. Cancer, heart disease, and orthopedic diagnostic errors were among the most common. Perhaps counterintuitively, misdiagnosis is more likely to happen with common illnesses and injuries than rare or exotic conditions, according to the report.

Schiff also notes that there is a mismatch between the modest resources available for research and the potential return-on-investment from improved diagnostic safety, especially considering the central role diagnosis plays in the delivery of health care:

Treatment of the wrong diagnosis is a wasteful and potentially harmful activity, yet is occurring every day. Virtually every patient needs an accurate and timely diagnosis; those who have been misdiagnosed are subjected to unnecessary treatment and side effects and repeated clinical encounters and testing.

Top-10 list is a beginning, not the end

Reflecting on diagnostic error’s position atop ECRI’s patient safety list, Schiff says he’s “not feeling like we’ve won a horse race.” Among a list of important problems, diagnostic error is now receiving attention that should enhance, not detract from, advancing safety in all areas.

ECRI agrees that the incoming tide of attention to these issues raises all boats. A press release explains, “Rather than highlight the most frequent or most harmful patient safety events, we issue the list to raise awareness and prompt discussion.”

To choose the Top 10, ECRI draws on the experience of its patient safety organization (PSO) members as well as the expertise of its staff and other professionals working in patient safety. Josi Wergin, Risk Management Analyst at ECRI Institute, explains:

This year, diagnostic errors were strongly represented in all the data sources that we used. We see event reports on diagnostic errors reported to our patient safety organization and our partner PSOs. Our members are asking us about diagnostic errors; they submitted multiple root-cause analyses and requests for custom research on this issue in the last year.

The list varies considerably from year to year, with no topics on the 2017 list reappearing in 2018. Each year, the list suggests resources health care organizations can use to address the 10 problems.


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