DIAGNOSTIC ERRORS:
Defining diagnostic errors in primary care involves the correct and timely identification of patients’ health problems, which relies on the expertise of healthcare providers and available resources. However, the complexity of clinical presentations and the high number of patients seen in primary care make it a high-risk area for errors. A diagnostic error occurs when a diagnosis is missed, delayed, or incorrect[1]. This can take various forms, such as overlooking a condition despite evident symptoms, providing the wrong diagnosis, or not communicating abnormal test results to the patient. These errors can occur at different stages of the diagnostic process, from initial assessments to follow-up and communication. Diagnostic errors represent missed opportunities to provide accurate and timely diagnoses based on available evidence. They can result from cognitive or system-related factors. To avoid hindsight bias, it is essential to identify evidence of omission or commission at the time the error occurred. Defining diagnostic errors in primary care involves the accurate and timely identification of patients’ health problems, which heavily relies on the expertise of healthcare providers and the resources available to them. However, the intricate clinical presentations and the high patient volume in primary care create a high-risk environment for errors. A diagnostic error occurs when a diagnosis is either missed, delayed, or incorrect. These errors can manifest in various ways, such as overlooking a condition despite clear symptoms, providing an inaccurate diagnosis, or failing to communicate abnormal test results to the patient. Such errors can happen at any stage of the diagnostic process, from initial assessments to follow-up and communication. Diagnostic errors signify missed opportunities to provide precise and timely diagnoses based on the available evidence[2]. They can stem from both cognitive and system-related factors[3]. To avoid hindsight bias, it is crucial to identify evidence of omission or commission at the specific time the error occurred.
Causes of diagnostic errors : Key factors
The diagnostic process is susceptible to errors in various aspects. Studies investigating diagnostic errors often reveal several root causes in each case. These causes may include cognitive errors, such as failing to properly synthesize available evidence or misusing physical examination or test data. In fact, evidence suggests that cognitive errors can be identified in over half of the cases involving diagnostic errors. Additionally, system flaws can contribute to diagnostic errors due to issues with communication or care coordination, problems with accessing medical record data, and insufficient access to specialists. A study conducted in a developed country found that process breakdowns were most frequently associated with the patient-practitioner clinical encounter (79%), followed by referral problems (20%), patient-related factors (16%), follow-up and tracking of diagnostic information (15%), and performance and interpretation of diagnostic tests (14%). Interestingly, almost half of all diagnostic errors involved more than one of these processes. The breakdowns in the patient-practitioner encounter were primarily related to problems with history-taking (56%), examination (47%), or ordering diagnostic tests for further evaluation (57%)[4].
The following factors can cause diagnostic process errors:
- Care coordination: Delays in consultations, misplaced test findings, or insufficient patient care documentation can all result in mistakes.
- Follow-up: Poor follow-up might impede the development of diagnostic impressions and lead to the loss of chances for a precise diagnosis.
- Healthcare affordability: Delaying or neglecting necessary medical care may result from prioritizing other fundamental requirements or from inability to afford healthcare.
- Healthcare provider education: Diagnostic accuracy can be impacted by inadequate training, particularly when clinical reasoning is not stressed enough, as well as by flaws in certification and license standards.
- Resources for health informatics are accessible: Healthcare professionals may struggle to get essential information if they have limited access to health informatics resources, such as the internet or medical information, especially in rural locations.
- Culture: Diagnostic errors may be influenced by punitive environments that hinder collaboration and learning, as well as physician-centric systems that downplay teamwork. Some patients might feel more comfortable receiving care in a passive manner.
- Human factors and cognitive problems: Errors in the diagnostic process can be caused by interruptions, disruptions, and the disorder of information in the work environment and systems[5].
Overall, it seems that the most common types of hazardous diagnostic mistakes in primary care include missed diagnoses of cancer, infections, and cardiovascular disease. These are each briefly discussed in turn.
[1] Graber ML, Franklin N, Gordon R. Diagnostic error in internal medicine. Arch Intern Med. 2005;165(13):1493-9. (Last accessed on 11.07.2023 at 11.00 am).
[2] Singh H, Giardina TD, Meyer AND, Forjuoh SN, Reis MD, Thomas EJ. Types and origins of diagnostic errors in primary care settings. JAMA Intern Med. 2013;173(6):418-25. (Last accessed on 11.07.2023 at 11.22 am).
[3] Singh H, Meyer and Thomas EJ. The frequency of diagnostic errors in outpatient care: estimations from three large observational studies involving US adult populations. BMJ Qual Saf. 2014;23(9):727-31. (Last accessed on 11.07.2023 at 11.32 am).
[4]https://apps.who.int/iris/bitstream/handle/10665/252410/9789241511636-eng.pdf