A report issued by the Agency for Healthcare Research and Quality dated December 15, 2022 entitled “Diagnostic Errors in the Emergency Department: A Systematic Review” found:

About 5.7% of patients seen in the emergency department (“ED”) receive an incorrect diagnosis with about 2.0% experiencing an adverse event because of the incorrect diagnosis; some of these adverse events are serious (~0.3%). This translates to about 1 in 18 ED patients receiving an incorrect diagnosis, 1 in 50 suffering an adverse event, and 1 in 350 suffering permanent disability or death.

Among the 130 million ED visits per year in the United States, 7.4 million patients are misdiagnosed, 2.6 million suffer an adverse event as a result, and about 370,000 suffer serious harms from diagnostic error. For an average ED with 25,000 visits annually and average diagnostic performance, this translates to over 1,400 diagnostic errors, 500 diagnostic adverse events, and 75 serious harms, including 50 deaths per ED, per year.

Five conditions (#1 stroke, #2 myocardial infarction, #3 aortic aneurysm/dissection, #4 spinal cord compression/injury, #5 venous thromboembolism) account for 39% of serious misdiagnosis-related harms, and the top 15 conditions account for 68%. Variation in diagnostic error rates by disease range from 1.5% for myocardial infarction to 56% for spinal abscess, with the other thirteen falling between 10% and 36%. Stroke, the top serious harm-producing disease, is missed an estimated 17% of the time. Among these 15 diseases, myocardial infarction is the only one with false negative rates near zero (1.5%), well below the estimated average rate across all diseases (5.7%).

Nonspecific or atypical symptoms increase the likelihood of error (for stroke, dizziness or vertigo increases the odds of misdiagnosis 14-fold over motor symptoms (those with dizziness and vertigo are missed initially 40% of the time)).

Female sex and non-White race were often associated with 20%–30% increases in misdiagnosis risk.

Measured diagnostic error rates vary up to 100-fold across hospitals. In individual studies, missed cases varied by hospital for subarachnoid hemorrhage (0% to 100%), myocardial infarction (0% to 29%), and appendicitis (1% to 16%). Error rates are usually found to be lower in academic/teaching hospitals, but it is unknown if this is an effect of increased availability/intensive use of diagnostic technologies or other factors.

Root causes of ED diagnostic errors were mostly cognitive errors linked to the process of bedside diagnosis. Medical malpractice claims associated with serious misdiagnosis-related harms involved failures of clinical assessment, reasoning, or decision-making in about 90% of cases. Similar findings were seen in incident report data.

The strongest, most consistent predictors of ED diagnostic error were individual case factors that increased the cognitive challenge of identifying the underlying disorder, with nonspecific, mild, transient, or “atypical” symptoms being the most frequent.

Source

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