Breakdowns in Process Are Key to Missed Diagnoses in Primary Care

Almost 80% of diagnostic errors identified in a small study of primary care physicians were the result of process breakdowns in the patient-practitioner clinical encounter, according to data published online in late February in JAMA: Internal Medicine.

Many of the diagnoses missed were for conditions commonly seen in primary care that also carry the potential for “moderate to severe harm.”

Breakdowns during the clinical encounter most commonly occurred 
• during history taking (56.3%) and physical examination (47.4%)
• when ordering further diagnostic tests  (57.4%), and
• as a result of failure to review previous documentation (15.3%).

Process breakdowns were also seen in the referral process (19.5%); follow-up and tracking of diagnostic information (14.7%); and performance and interpretation of diagnostic tests (13.7%).

The study identified 190 unique diagnostic errors, defined as missed, delayed, or wrong diagnoses at a large Veterans Affairs facility and a large private health care system. Of the 190 cases, 68 unique diagnoses were missed, including pneumonia (6.7%), decompensated congestive heart failure (5.7%), acute renal failure (5.3%), cancer (5.3%), and urinary tract infection (4.8%).

The abstract of the study is available here.

The full text of the invited commentary can be viewed here.