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Patient Safety & Misdiagnosis

Monday, May 22, 2017  
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Patient Safety & Misdiagnosis

Charles David Cash

FollowCharles David Cash

Assistant Vice President, Risk Management, at PRMS,

Specialists in Professional Liability Insurance Programs

Let’s consider misdiagnosis, which is a significant cause of patient injury and death. According to theAgency for Healthcare Research and Quality, misdiagnosis “accounted for 17% of preventable errors in hospitalized patients,” and autopsy studies indicate that “approximately 9% of patients experience a major diagnostic error that went undetected while the patient was alive.”

Missed or delayed diagnosis is a frequent cause of claims and lawsuits. The Psychiatrists’ Program’s® cause of loss data shows that “incorrect diagnosis” accounts for 6% of the claims and lawsuits against psychiatrists. Missed or delayed diagnosis also increases the risk of additional errors in treatment when faulty diagnoses are relied on to make subsequent – and incorrect – treatment decisions.

Fortunately, not every missed or delayed diagnosis necessarily means that the psychiatrist was negligent. Generally, three categories of diagnostic error (and their potential causes) are recognized in the literature:


Potential causes:unreliable information from the patient (unintentional), malingering, factitious disorders, patient refuses testing or needed studies, atypical presentation of the condition, information not known about the condition


Potential causes:organization problems, inefficient processes, difficulty with teamwork, poor communication

Cognitive (pitfalls in reasoning)

Missed or delayed diagnosis is rarely due to a lack of requisite knowledge. Rather, the provider relies inappropriately on heuristics, leading to a cognitive failure in synthesizing data and exercising judgment.

I’ll focus here on cognitive errors.

Psychiatrists, and physicians generally, rarely march step-by-step through a differential diagnosis. Rather, theycommonly rely on heuristics, shortcuts in diagnostic reasoning, to drive many diagnostic decisions. Heuristics are cognitive biases, based on underlying truth. They are commonly used, generally very accurate, and save time and money. However, heuristics occasionally can lead the psychiatrist down the wrong diagnostic path. Some common heuristics and their pitfalls include:

Availability heuristic– a diagnosis is chosen by the ease with which it comes to mind; draws on experience with past cases to reach a diagnosis for the current patient

Pitfalls:assumes the current patient is representative of all patients with the condition, dismisses the possibility of an atypical presentation

Anchoring heuristic– a psychiatrist sticks with an initial diagnosis even when contrary information presents itself

Pitfalls:failure to adjust diagnostic decisions when additional information is dismissed

Representativeness heuristic– diagnostic certainty is gauged by the extent the current patient matches the psychiatrist’s expectations

Pitfalls:anticipates only conformity in the current patient’s presentation, dismisses the possibility of an atypical presentation

Blind obedience heuristic– a psychiatrist defers to test results or consultants’ opinions

Pitfalls:ignores the possibility of faulty test results or opinions of experts

Risk Management

Over the years, we Risk Managers have organized our risk management advice into the “Three C’s,” and that has served us well. To help reduce the risk of diagnostic error, please consider the following risk management advice:

Collect information

Conduct a comprehensive history and appropriate examination, including gathering collateral information from family and other sources

Consider using assessment and treatment guidelines, and documenting your reasons for deviating from them when they are not appropriate for a particular patient

Follow up on laboratory and other tests


Obtain consultations from colleagues

Educate patients that it is not uncommon for good doctors to disagree about difficult-to-diagnose illnesses and that there are few absolute tests to verify a clinical diagnosis of psychiatric conditions

Carefully document

The treatment record should reflect reasoned/prudent approach to diagnosis, consideration of differential diagnosis, history and physical examination, and testing

If a working diagnosis is made and then changed, document what led to the change. For example:

what information became available

what changed about the patient’s condition

what additional lab work, consultation, etc. became available

The Fourth “C” – Cognitive process monitoring

For purposes of this post, I’m going to add a fourth “C” – cognitive process monitoring. The goal should not be to eliminate heuristics from diagnostic reasoning, but to recognize the pitfalls of heuristics and correct course when needed. Some authors have referred to this process as meta-cognition or de-biasing; essentially it’s monitoring one’s own cognitive processes.

It is important to identify and reflect on each of the heuristics known to affect subconscious processing and see if your diagnosis involves the use of heuristic reasoning. A reasonable strategy might include these steps:


What should I ask, think, examine?

Do I feel comfortable about my own judgment?

Does the patient feel comfortable with my judgment?


Does it make clinical sense?

Did I put enough effort towards thinking about this case?

Did I have biases when thinking about this case?

Keep asking questions:

Why does this lab value not make sense?

Why does the family seem skeptical of the diagnosis?

What can I not explain?

The goal of this strategy is to shift from heuristic reasoning and more toward analytical thinking. Other activities can reduce the risk of misdiagnosis. Among others, a psychiatrist could assume that her working diagnosis is incorrect and ask herself, “What alternatives should be considered?” If you do make a diagnostic error, conduct a “cognitive autopsy” to identify whether heuristics contributed to the missed diagnosis.

A large body of literature exists on this topic. Additionally, theSociety for Medical Decision Making(SMDM) is a scholarly organization promoting sound approaches to clinical decision-making.

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