Diagnostic error in medicine: Analysis of 583 physician-reported errors

Archives of Internal Medicine

Volumn 169, Issue 20, 2009, Pages 1881-1887

  Schiff, Gordon D ^a,b,c   Hasan, Omar ^b   Kim, Seijeoung ^a,d   Abrams, Richard ^c   Cosby, Karen ^a   Lambert, Bruce L ^d   Elstein, Arthur S ^d   Hasler, Scott ^c   Kabongo, Martin L ^e   Krosnjar, Nela ^a   Odwazny, Richard ^c   Wisniewski, Mary F ^a   McNutt, Robert A ^c  

^a Jr Hospital of Cook County   (United States)

^b BRIGHAM AND WOMEN S HOSPITAL   (United States)

^c RUSH MEDICAL COLLEGE   (United States)

^d UNIVERSITY OF ILLINOIS AT CHICAGO   (United States)

^e UNIVERSITY OF CALIFORNIA   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ACUTE CORONARY SYNDROME; ARTICLE; BREAST CANCER; CLINICAL ASSESSMENT; COLORECTAL CANCER; CONSULTATION; DELAYED DIAGNOSIS; DIAGNOSTIC ERROR; FOLLOW UP; HUMAN; LABORATORY TEST; LUNG CANCER; LUNG EMBOLISM; MAJOR CLINICAL STUDY; PATIENT REFERRAL; PHYSICAL EXAMINATION; PHYSICIAN; PRIORITY JOURNAL; STROKE;

ATTITUDE OF HEALTH PERSONNEL; CLINICAL COMPETENCE; DIAGNOSTIC ERRORS; FEMALE; HEALTH CARE SURVEYS; HUMANS; INCIDENCE; INTERNAL MEDICINE; MALE; OBSERVER VARIATION; OUTCOME ASSESSMENT (HEALTH CARE); PHYSICIAN'S PRACTICE PATTERNS; PILOT PROJECTS; PROFESSIONAL PRACTICE; QUESTIONNAIRES; REPRODUCIBILITY OF RESULTS; RISK ASSESSMENT; UNITED STATES;

EID: 70449643252     PISSN: 00039926     EISSN: 15383679     Source Type: Journal    
DOI: 10.1001/archinternmed.2009.333     Document Type: Article

References (35)

1. Leape LL, Brennan TA, Laird N, et al. The nature of adverse events in hospitalized patients: results of the Harvard Medical Practice Study II. N Engl J Med. 1991; 324(6):377-384.
2. Thomas EJ, Studdert DM, Burstin HR, et al. Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care. 2000;38(3):261-271.
3. Schiff GD, Kim S, Abrams R, et al. Diagnosing diagnostic errors: lessons from a multi-institutional collaborative project. In: Advances in Patient Safety: From Research to Implementation. Vol 2. Agency for Healthcare Research and Quality Web site. www.ahrq.gov/qual/advances. Accessed July 10, 2009.
4. Graber M. Diagnostic errors in medicine: a case of neglect. Jt Comm J Qual Patient Saf. 2005;31(2):106-113.
5. Newman-Toker DE, Pronovost PJ. Diagnostic errors - the next frontier for patient safety. JAMA. 2009;301(10):1060-1062.
6. Goldman L, Sayson R, Robbins S, Cohn LH, Bettmann M, Weisberg M. The value of the autopsy in three medical eras. N Engl J Med. 1983;308(17):1000- 1005.
7. Sonderegger-Iseli K, Burger S, Muntwyler J, Salomon F. Diagnostic errors in three medical eras: a necropsy study. Lancet. 2000;355(9220):2027-2031. (Pubitemid 30339240)
8. Shojania KG, Burton EC, McDonald KM, Goldman L. Changes in rates of autopsy detected diagnostic errors over time. JAMA. 2003;289(21):2849-2856.
9. Kirch W, Schafii C. Misdiagnosis at a university hospital in 4 medical eras. Medicine (Baltimore). 1996;75(1):29-40.
10. Phillips RL 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(2):121-126.
11. CRICO/RMF forum. CRICO/RMF Web site. www.rmf.harvard.edu/high-risk areas /diagnosis/index.aspx. Accessed August 14, 2009.
12. McNutt R, Abrams R, Hasler S. Diagnosing diagnostic mistakes: case and commentary. emergency medicine, spotlight case. Agency for Healthcare Research and Quality Web site. http://www.webmm.ahrq.gov/case.aspx?caseID=95. Accessed August 14, 2009.
13. Singh H, Thomas EJ, Khan MM, Petersen LA. Identifying diagnostic errors in primary care using an electronic screening algorithm. Arch Intern Med. 2007; 167(3):302-308. (Pubitemid 46256550)
14. Milch CE, Salem DN, Pauker SG, Lundquist TG, Kumar S, Chen J. Voluntary electronic reporting of medical errors and adverse events: an analysis of 92,547 reports from 26 acute care hospitals. J Gen Intern Med. 2006;21(2):165-170. (Pubitemid 43363673)
15. Rowin EJ, Lucier D, Pauker SG, Kumar S, Chen J, Salem DN. Does error and adverse event reporting by physicians and nurses differ? Jt Comm J Qual Patient Saf. 2008;34(9):537-545.
16. Phillips RL, Dovey SM, Graham D, Elder NC, Hickner JM. Learning from different lenses: reports of medical errors in primary care by clinicians, staff and patients. J Patient Saf. 2006;2:140-146.
17. Gandhi TK, Kachalia A, Thomas EJ, et al. Missed and delayed diagnoses in the ambulatory setting: a study of closed malpractice claims. Ann Intern Med. 2006; 145(7):488-496. (Pubitemid 46780952)
18. Kachalia A, Gandhi TK, Puopolo AL, et al. Missed and delayed diagnoses in the emergency department: a study of closed malpractice claims from 4 liability insurers. Ann Emerg Med. 2007;49(2):196-205. (Pubitemid 46108135)
19. Singh H, Thomas EJ, Petersen LA, Studdert DM. Medical errors involving trainees: a study of closed malpractice claims from 5 insurers. Arch Intern Med. 2007; 167(19):2030-2036. (Pubitemid 350036701)
20. Fischhoff B. Hindsight not equal to foresight: the effect of outcome knowledge on judgment under uncertainty. Qual Saf Health Care. 2003;12(4):304-312.
21. Neugebauer R, Ng S. Differential recall as a source of bias in epidemiologic research. J Clin Epidemiol. 1990;43(12):1337-1341.
22. Epstein RM. Mindful practice. JAMA. 1999;282(9):833-839.
23. Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med. 2003;78(8):775-780. (Pubitemid 36993075)
24. Mamede S, Schmidt HG, Rikers R. Diagnostic errors and reflective practice in medicine. J Eval Clin Pract. 2007;13(1):138-145. (Pubitemid 46238808)
25. Schiff GD. Minimizing diagnostic error: the importance of follow-up and feedback. Am J Med. 2008;121(5)(suppl):S38-S42.
26. Kostopoulou O, Delaney BC, Munro CW. Diagnostic difficulty and error in primary care - a systematic review. Fam Pract. 2008;25(6):400-413.
27. Schiff GD, ed. Getting Results: Reliably Communicating and Acting on Critical Test Results. Oakbrook Terrace, IL: JCHAO; 2006.
28. Wahls T, Haugen T, Cram P. The continuing problem of missed test results in an integrated health system with an advanced electronic medical record. Jt Comm J Qual Patient Saf. 2007;33(8):485-492.
29. Nepple KG, Joudi FN, Hillis SL, Wahls TL. Prevalence of delayed clinician response to elevated prostate-specific antigen values. Mayo Clin Proc. 2008; 83(4):439-445.
30. Kassirer JP, Kopelman RI. Cognitive errors in diagnosis: instantiation, classification, and consequences. Am J Med. 1989;86(4):433-441.
31. Graber M, Gordon R, Franklin N. Reducing diagnostic errors in medicine: what's the goal? Acad Med. 2002;77(10):981-992. (Pubitemid 35157779)
32. Graber ML, Franklin N, Gordon R. Diagnostic error in internal medicine. Arch Intern Med. 2005;165(13):1493-1499.
33. Roberts WC. The autopsy: its decline and a suggestion for its revival. N Engl J Med. 1978;299(7):332-338.
34. Hill RB. The current status of autopsies in medical care in the USA. Qual Assur Health Care. 1993;5(4):309-313.
35. Xiao J, Krueger GR, Buja LM, Covinsky M. The impact of declining clinical autopsy: need for revised healthcare policy. Am J Med Sci. 2009;337(1):41-46.