As much as we as nurse practitioners try to be thorough, we occasionally miss a diagnosis. Sometimes it’s a case of “you don’t know what you don’t know”, other times it’s a matter of sloppiness, or, perhaps you miss a diagnosis simply because a medical problem presents atypically. Understanding what areas of our practice are most vulnerable to mess ups can help us avoid them in the future. So, let’s talk about diagnostic errors. Where do things go wrong in the determining what’s wrong with our patients?
Attaching a diagnosis to a patient seems simple enough. When testing or clinical judgement gives you definitive information to go on, you can diagnose a medical problem quite specifically. A closed, compound fracture of the distal radius doesn’t leave much room for interpretation. Vague complaints, or those that require further workup are more generalized. A diagnosis of “abdominal pain”, for example, doesn’t give much to go on. Regardless of the specificity of your identification, mistakes can be made in the determining the best steps for treating your patients.
Looking at more than 47,000 diagnosis-related malpractice cases, Crico Strategies, a division of Harvard Medical Institutions, has compiled some compelling data identifying where healthcare providers often go wrong when it comes to diagnosing their patients. Here’s what they found.
Where do most diagnostic failures occur?
Most diagnostic failures occur in ambulatory care settings, for example family practice clinics and urgent care clinics. Ambulatory care errors account for 57% of diagnosis-related malpractice cases. Inpatient care accounts for an additional 26% of cases while diagnostic errors in the emergency department make up the remaining 16% of diagnosis-related malpractice cases.
What diagnoses are healthcare providers missing?
In the ambulatory care setting, the most commonly missed diagnoses are cancer, heart disease, and orthopedic injury. In the inpatient setting, the most commonly missed diagnoses are complications of an existing medical problem, heart disease, and cancer. Finally, in the emergency department the most commonly missed and misdiagnosed conditions include orthopedic injury, heart disease, and stroke. Overall, the most commonly missed cancers include breast cancer, lung cancer and colorectal cancer.
What specialties are most commonly involved in diagnostic errors?
Nurse practitioners, physician assistants, and physicians working in general medicine specialties are most commonly at risk when it comes to diagnostic errors. This includes healthcare providers working in family medicine, internal medicine, and gastroenterology. Surgeons are involved in 17% of malpractice cases resulting from diagnostic errors while radiologists are involved in 15% of these types of cases.
What’s going wrong in the diagnostic process?
Diagnosing patients involves a number of steps. So, there are a variety of ways the process can go wrong. Lapses in clinical judgement account for the most errors, at fault in 73% of diagnosis-related malpractice cases. Failure on part of the patient to adhere to the care plan and communication breakdown complete the list of missteps in the diagnostic process.
Where does lapse in clinical judgement typically occur?
With lapses in clinical judgement being so common, it’s important to understand where and why this breakdown in judgement occurs. Here are the most common reasons:
- Failure to or delay in ordering a diagnostic test (31%)
- Misrepresentation of a diagnostic test (23%)
- Failure to establish a differential diagnosis (22%)
- Failure to or delay in obtaining a consult or referral (18%)
- Failure to rule-out an abnormal finding (8%)
What can we learn from these findings?
Overall, the diagnostic process can be broken down into three steps including initial assessment, testing/results processing, and follow-up/coordination. Each step has vulnerabilities where providers may slip up.
When you initially assess a patient, complete a thorough history and physical including the patient’s risk for problems like cancer and heart disease. This helps ensure you won’t miss a diagnosis. Make sure that noted problems receive timely care to avoid delays in testing and treatment. Thoroughly address each of the patients complaints making sure none is overlooked. Don’t forget to establish (and document!) differential diagnoses to help guide your care.
Testing and Results Processing
It can be tempting to rely heavily on tests to make your diagnosis. When you do so, you make assumptions. Many tests are not definitive. If a clinical picture doesn’t fit with a test result, speak up. It may be the radiologist or lab technician who is wrong. Interpret test results appropriately making sure you take the next best steps based on the findings.
Follow-Up and Coordination
As nurse practitioners we’ve all personally experienced problems with patient follow-up and coordination of care. You must take care in referring patients to other providers and ordering consults. Patient must be given a reasonable method of and timeframe for follow-up.
Missing diagnoses and mistaken diagnoses will happen. But, if you’re prudent in the steps you take to make your judgements and understand where errors are most likely to happen you will significantly improve the accuracy of your diagnostic process.
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