Missed and Erroneous Diagnoses Common in Primary Care Visits

Graber, Mark Mark.Graber at VA.GOV
Fri Dec 6 02:25:07 UTC 2013

Rob - thanks for the opportunity to reflect on Hardeep's studies.  Although the focus of the paper was on how well 'trigger tools' worked in helping detect diagnostic errors, there were 3 findings from this and his related papers that in my view are really important:

"First, no differential diagnosis was documented at the index visit in 81.1% of cases"   That's a remarkable finding.  It speaks to the problem of overconfidence and the too-common tendency we all have to satisfice on the first diagnosis that seems to explain all the facts at hand.  How many errors could be avoided if we just thought a little more broadly?  Completing even a modest differential diagnosis might accomplish that.

"Most of the errors identified in our study involved missed diagnosis of a large variety of
common conditions as opposed to either a few selected conditions or rare or unusual diseases."   This corroborates findings from Olga Kostopoulou and others:  Yes, we are likely to miss some rare diseases, but MOST of the diagnostic errors made involve common conditions.  In Hardeep's study these included pneumonia, heart failure, urinary tract infections, etc.  Common stuff.

3.  From Hardeep's data you can calculate an incidence of diagnostic error in ambulatory care:  "Singh et al found that roughly 0.1% of all primary care visits were associated with missed opportunities
to make an earlier diagnosis and prevent "considerable harm."  This is from David Newman-Toker's editorial where he did the math on this.(Measuring diagnostic errors in primary care.  JAMA Intern Med 2013 173(6): 425-6.)  It sounds like we're doing a good job when you think of harm-related errors as being found only once in every 1000 visits, but when you consider that there a half BILIION such visits each year annually, that's a lot of harm.  So the answer to your question is: YES, PRIMARY CARE IS WHERE MOST OF THE ERRORS ARE MADE.  If my math is correct (assuming roughly 5000 hospitals in the US and 500 clinic visits every day), this is what the national and local stats look like.  Its a shocking set of statistics.

Mark Graber, MD FACP


From: robert bell <rmsbell at ESEDONA.NET>
Reply-To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>, robert bell <rmsbell at ESEDONA.NET>
Date: Thu, 5 Dec 2013 16:29:10 -0500
Subject: [IMPROVEDX] Missed and Erroneous Diagnoses Common in Primary Care Visits


This was published earlier in the year.


Is it Primary Care where most diagnostic errors are made?!

Rob Bell

Moderator: Lorri Zipperer Lorri at ZPM1.com, Communication co-chair, Society for Improving Diagnosis in Medicine

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