Missed and Erroneous Diagnoses Common in Primary Care Visits

Kohn, Michael Michael.Kohn at UCSF.EDU
Sun Dec 8 06:23:33 UTC 2013

In sick (i.e. symptomatic) patients, there are two kinds of diagnostic error: we can fail to identify and treat the disease that is causing the illness or we can misdiagnose and inappropriately treat a disease that isn't causing the illness.

One of the participants on this thread mentioned pernicious anemia.  The Lisa Sanders book (Chapter 9) has an example of a delayed diagnosis of that disease.  I could see missing this as an explanation for chest pain in a busy ED and recommending outpatient evaluation, but it's hard to believe that it wouldn't be picked up eventually.    We also have to worry about overdiagnosis/misdiagnosis.  See Chapter 8 on chronic Lyme Disease.

Reducing both kinds of diagnostic error is a challenge.  Computerized decision support tools integrated into the EHR may be part of the answer, but we're not there yet.


Michael A. Kohn, MD, MPP

Associate Professor

Epidemiology and Biostatistics

Emergency Physician

Mills-Peninsula Medical Center

From: Alan Morris [Alan.Morris at IMAIL.ORG]
Sent: Saturday, December 07, 2013 4:55 PM
Subject: Re: [IMPROVEDX] Missed and Erroneous Diagnoses Common in Primary Care Visits

I propose that an error is any deviation from the intended, evidence-based, target decision.  Some errors are trivial and of little consequence.  Some carry a major risk to the patient. In an unusually tightly controlled ICU at the Hebrew University Hospital in Jerusalem, Gopher et al. reported about 174 clinician interactions/patient/day.  99% of these clinician interactions were performed correctly by RNs and MDs. (It is the rare, if any, clinical unit that can aspire to a 99% correct performance rate.)  However, the 1% error rate led to a major threat to life or limb per patient every other day, on average!  Most people think that technical rock climbing is a dangerous activity.  However, few climbers would ever tie onto a rope and climb, if they thought they would be subjected to a major threat to life or limb every other day because of error.

Surprising low clinician error rates associated with almost unachievable correct performance, can lead to unacceptable risks to patients.

Extrapolating these ICU data to the outpatient setting is difficult.  Nevertheless, I believe we should pay attention to all errors, and categorize them with respect to patient risk.

Have  a nice day.

Alan H. Morris, M.D.
Professor of Medicine
Adjunct Prof. of Medical Informatics
University of Utah

Director of Research
Director Urban Central Region Blood Gas and Pulmonary Laboratories
Pulmonary/Critical Care Division
Sorenson Heart & Lung Center - 6th Floor
Intermountain Medical Center
5121 South Cottonwood Street
Murray, Utah  84157-7000, USA

Office Phone: 801-507-4603
Mobile Phone: 801-718-1283
Fax: 801-507-4699
e-mail: alan.morris at imail.org
e-mail: alanhmorris at gmail.com

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