The Big Three

A newly released analysis of almost 12,000 medical malpractice claims sponsored by the Society to Improve Diagnosis in Medicine (SIDM), found that the three most common misdiagnoses leading to harm include vascular events, infections, and cancers. These events make up 75% of diagnostic errors leading to patient harm. 

According to David E. Newman-Toker, MD, Ph.D., professor of Neurology at Johns Hopkins University, “Diagnostic errors are the most common, most catastrophic, and most costly medical errors both for society and for individual patients.” He suggests these three areas are where we should focus our efforts to reduce diagnostic errors. 

Dr. Newman-Toker elaborates stating, “diagnostic errors account for 34% of all medical errors that cause serious harm; 64% of such errors lead to death or permanent disability. They account for 28% of all payouts for medical malpractice claims. The median payout is $766,000 per highly severe case”. 

Within each of the “big three” categories, the authors identified five specific diseases or conditions that together accounted for about 50% of serious harms — equally distributed between death and permanent disability — in the claims data. In the vascular category, these were stroke, venous and arterial thromboembolismmyocardial infarction, and aortic aneurysm and dissection. Among infections, the top five were sepsis, pneumonia, meningitis/encephalitis, and spinal abscess. Types of cancer most associated with misdiagnosis were lung cancer, colorectal cancerbreast cancermelanoma, and prostate cancer.

The study also revealed the distribution of diagnostic errors by practice setting. Cancer diagnostic errors were more likely to occur in the clinic, whereas vascular event- and infection-related diagnostic errors were more likely to occur in inpatient and emergency department settings. Infection-related misdiagnoses were also common in pediatric clinic settings.

Proposed solutions include increased collaboration, improved clinician training, active listening (the patient will always tell you their diagnosis), access to diagnostic assistance within the ERM, and broad collaboration within local hospital systems and organizations nationwide. The authors were clear in stating the blame should not be placed at the feet of clinicians, but instead, are focused on finding practical solutions.

National-level efforts include collaborations between leading healthcare experts. The American Board of Internal Medicine, the American Academy of Family Physicians, the American Academy of Pediatrics, the American Association of Nurse Practitioners, the American College of Emergency Physicians, the American Association of Medical Colleges, and the Society of Hospital Medicine have all joined the Coalition to Improve Diagnosis. This organization was created in 2015 by SIDM and brings together professional societies, healthcare management organizations, hospital/health systems, patient organizations, medical education and training programs, insurers, quality and safety groups, measurement/assessment boards, laboratory organizations, and federal liaisons. Additionally, the SIDM supports Congressional funding to establish centers of diagnostic excellence across the country. They postulate these centers would support research on improving diagnosis, encourage partnerships among institutions so proposed solutions can be quickly put into clinical practice, and create a diagnostic research group.

The findings of the study analysis are not surprising since what researchers considered the most common missed diagnoses are among some of the most common high-risk diagnoses clinicians encounter. These conditions have a high mortality rate regardless of the care the patient receives. For instance, sepsis has an inherently high mortality rate in any patient population, as does pneumonia in the elderly.  Most vascular events have a high mortality rate due to the nature of the disease and the need for immediate intervention if there is any chance of survival, which is not routinely available. Furthermore, the analysis is limited to a review of malpractice cases. Many of the malpractice claims may not meet the criteria of diagnostic error and are instead unfortunate injuries and deaths that occurred as a consequence of a high-risk disease process. Improved diagnostic techniques and methods are always welcome, even if accomplished through potentially manipulated data analysis. Additionally, with a median payout of $766,000, this study highlights the need for sweeping tort reform. 

Cynthia R Stuart DO

Dr. Stuart is Board Certified in Family Medicine. Originally from Georgia, she spent most of her youth in Miami, Florida and has been a Texas resident since the early 1990s. She attended UNTHSC-Fort Worth and completed her residency at UTSW/Methodist Hospital System where she was Chief Resident in her senior year. She is an Associate Professor at UTSW and UNTHSC, participating as a preceptor for medical students and residents. She completed a two-year course at SMU Cox School of Business in Advanced Leadership that enables her to advocate for quality health care providers and local public health programs in her community. She is the head of the Credentials Committee, sits on the Medical Executive Committee and the Ethics Committee at Baylor Scott and White Hospital of Carrollton. She has appeared on numerous news and radio programs to educate the public about various health topics. Dr. Stuart has managed her private practice in Carrollton since 2005 and is now a Direct Primary Care Physician.