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The Impact of Missed Diagnoses on ER Outcomes

April 1, 2021
April 1, 2021

Missed diagnoses can have a huge impact on outcomes in the emergency department. This blog post is the first of several based on a recent HealthStream webinar, “Missed Diagnosis in the ER: The Silent Tragedy.” 

For professionals that choose emergency care as their career, this environment is one in which they thrive. There’s quick decision-making based on systematic trauma, triage, and assessment scales. There’s rapid collection, feedback, and intervention from diagnostic tests, and collaborative decision-making within inter-professional teams. These are the hallmarks of trauma events. There is a collective downside to this intense environment, and that is the human toll, the loss of life. Yet, staff tend to be able to rationalize these losses and move on with a genuine feeling of, “I did everything possible.”

Ironically, two rooms down, your organization’s next tragedy could be occurring. The impact of the tragedy to this patient, his or her family, the staff, and the organization could be even more profound than the chaotic sudden tragedy occurring two doors to the right in the other direction there. These are the phases of missed diagnoses.

Examining the Data about Missed Diagnoses

Dr. Hardeep Singh is the first research physician to provide robust population-level data on the impact of missed diagnoses problems in outpatient setting. For his efforts, he received the prestigious Presidential Early Career Award for scientists and engineers from President Barack Obama. His research had two significant statistics. First, at least 1-in-every-20 adults who seek medical care in the US, emergency rooms or community health clinics, may walk away with the wrong diagnosis. At that estimate, 12 million Americans a year could be affected. Then, in the study of return visits, more than 5% of the original diagnoses were wrong, and the actual problem could have easily been detected in triage during the original visit. This data speaks volumes about the two areas of great concern for most organizations. One, the potential for litigation and, two, return visits within 24 hours of a prior visit within the ER; both have potential financial impact.

Expanding on his study, the Institute of Medicine (IOM) Quality Chasm Series extended out beyond his original studies—they got a group of people together, a group of 21 quality, medical, and legal professionals, to create the National Academies of Science, Engineering, and Medicine (NASEM). Their charge was to provide insight into the prevalence and potential causes of missed diagnoses and to establish strategies that healthcare organizations could implement to reduce the occurrences within their organization. In 2015, this group released the report improving diagnoses in health care.

5% Are Missed Diagnoses, Contributing to 10% of Patient Deaths

These are some of the substantial findings that they also found during this report development: 5% of adults who seek outpatient care experience a diagnostic error, postmortem examinations spanning decades reveal diagnostic errors contributed to approximately 10% of all patient deaths, medical records reviews suggest diagnostic errors accounted for 6% to 17% of adverse events, diagnostic errors are the leading type of medical malpractice claims and are two times as likely to have resulted in patient death compared to other claims and represent the highest proportion of total payouts.

Four Contributors to Missed Diagnoses

What is the cost of getting a diagnosis wrong? Most of us are very familiar with what is called the Swiss cheese effect, and this diagnosis serves as a great example of when all the proverbial holes in the cheese lineup. This IOM study identified four major things or holes that led to an increase in missed diagnoses. Number one was insufficient training. Number two was health information technology. So our EMR too much of it, not enough of it; told us things, but didn’t tell us things. Risky staff behavior. In the world of just cause where most of us are now practicing, we understand what risky staff behavior is, and we try to quickly identify and eradicate it; however, it still occurs. Then, the ever-looming time constraints and where more so do we see this in our ERs, in our acute care setting.

The Houston VA Health Service Research and Development Center of Excellence has identified that most processed breakdowns are related to the clinical encounter and is a part in the clinical encounter where the practitioners are almost always pressed for time to make a decision. They go on to add that there’s a need to focus on basic clinical skill and related cognitive processes, for example, data gathering within the medical history and physical examination, and then the actual synthesis of the information that is gathered. Essentially, our ERs are a traveling superhighway of holes in the cheese.

Watch the full webinar recording.