When people think they might be having a heart attack, a stroke or some other really serious health event, they head for the nearest emergency room. Such patients are often in pain, anxious, afraid and very vulnerable. They assume the health professionals in the emergency department will quickly determine what’s wrong and provide prompt treatment. What if those assumptions are wrong? A recent analysis published in JAMA (Jan. 27, 2023) reveals that millions of people are misdiagnosed in emergency rooms each year. That can lead to inappropriate or delayed treatment. In the worst case scenario, it can lead to death. How can you prevent being misdiagnosed in the ER or in a doctor’s office?
An Accurate Diagnosis Is NOT Easy!
The word diagnosis comes from the Greek word gnosis, which means to know or knowledge. The prefix “dia” implies discerning or telling things apart. In medicine, diagnosis is the crucial first step in determining what is causing a patient’s symptoms.
If the diagnosis is correct, the doctor is more likely to offer the right treatment. That could be a drug or a surgical intervention. When the diagnosis is wrong, however, it can cause a great deal of hardship.
Chaos in the ER:
Let’s face it, emergency rooms are challenging for everyone involved. First comes triage. Someone has to determine if the “emergency” is life threatening and needs immediate attention or if it is “just” unpleasant and can wait awhile.
By the way, “triage” comes from the French term “‘trier,’ which is used to describe the process of sorting and organization” (StatPearls, Aug. 31, 2022):
“Triage is utilized in the healthcare community to categorize patients based on the severity of their injuries and, by extension, the order in which multiple patients require care and monitoring.”
Triage decisions are often made by nurses or PAs (physician associates). They have a really challenging job. There are often lots of people in the waiting room. Some may have a nasty rash that could turn into life-threatening anaphylactic shock or just go away over time. Others may be bleeding internally but not show any obvious signs of hemorrhage. People who report dizziness could be suffering a stroke or experiencing something “mild” called BPPV (benign paroxysmal positional vertigo).
How Often Are People Misdiagnosed in the ER?
The Agency for Healthcare Research and Quality (AHRQ) wanted to know about diagnostic mistakes in emergency departments. It commissioned a “Systematic Review” (Dec. 15, 2022).
Here is the executive summary:
“Overall diagnostic accuracy in the emergency department (ED) is high, but some patients receive an incorrect diagnosis (~5.7%). Some of these patients suffer an adverse event because of the incorrect diagnosis (~2.0%), and some of these adverse events are serious (~0.3%). This translates to about 1 in 18 ED patients receiving an incorrect diagnosis, 1 in 50 suffering an adverse event, and 1 in 350 suffering permanent disability or death. These rates are comparable to those seen in primary care and hospital inpatient care.
“We estimate that among 130 million emergency department (ED) visits per year in the United States that 7.4 million (5.7%) patients are misdiagnosed, 2.6 million (2.0%) suffer an adverse event as a result, and about 370,000 (0.3%) suffer serious harms from diagnostic error. Put in terms of an average ED with 25,000 visits annually and average diagnostic performance, each year this would be over 1,400 diagnostic errors, 500 diagnostic adverse events, and 75 serious harms, including 50 deaths per ED.”
“Only” 7.4 Million People Misdiagnosed in the ER!
Is the glass half empty or half full? The idea that 1 out of 18 patients will be misdiagnosed in the ER scares the heck out of us. Some health care professionals will pat themselves on the back and say that they got it right 17 out of 18 times. Is that something to be proud of?
Imagine the pilot of an airplane bragging that he arrived at the right airport 17 out of 18 times. If he added that he “only” screwed up 1 out of 18 times, how long would he stay employed as a pilot?
On October 21, 2009, two pilots became distracted on their way from San Diego to Minneapolis. They overshot their destination by more than 150 miles. When they realized their error they had to do a U-turn and head back to Minneapolis.
The pilots of Northwest Airlines Flight 188 landed the plane safely, but it was an hour behind schedule. These two pilots became targets for jokes. It wasn’t long before their licenses were revoked by the Federal Aviation Administration.
No one was hurt. No one died. But the pilots were severely sanctioned. Health professionals who make diagnostic errors are rarely sanctioned, even when they cause harm to patients.
Statistics Are Boring…People Are Real!
Long waits and overcrowding have become the norm in many hospital emergency rooms. We hear from people who have had to wait 8 hours or longer to be seen by a doctor. Sometimes they are stuck overnight in a hallway.
Emergency departments are often understaffed. A report from Kaiser Health News and NPR documents that many hospitals are cutting back on emergency physicians to save money. The reporters attribute this to private equity investors buying up the medical staffing companies that provide hospitals with ER doctors.
That 1,400 patients will be misdiagnosed in the average ER each year is alarming. We find it even more disheartening that on average 50 people will die in that typical hospital annually because they were misdiagnosed in the emergency department.
Readers Report Being Misdiagnosed in the Emergency Room:
Statistics do not convey the impact of such mistakes, though. Visitors to our website have shared their own stories.
One reader wrote:
“I woke up not feeling well, with the worst headache ever in the back of my head and sick to my stomach. At the emergency room, I explained my symptoms, along with the facts that I’m 73 and have high blood pressure.
“The doctor gave me three Tylenol and IV fluid. When severe pain started in my right arm, I was told it was because the blood pressure cuff was too tight.
“A CT scan showed nothing, so they let me go. On the way home, I stopped at a store. As I walked out, my right arm and leg went completely numb. I drove back to the hospital and an MRI showed I had a stroke.
“CT scans don’t always show a stroke is imminent. There was a complete disregard for my health, maybe because I’m a woman of a certain age. This was a really terrible response to a life-threatening situation.”
Another reader also experienced a delay in diagnosis:
“I went to the ER with pain in my left flank when I inhaled. The doctor ordered a scan and told me I might have a mild case of pneumonia. He prescribed 10 days of antibiotic.
“That night, the pain got worse. I called my PCP the next day and was told to go to the ER. When I contacted the ER, they wouldn’t see me since I had been there the day before. I went home disappointed.
“My husband literally hauled me to the car and drove back to the ER. A different doctor ordered a thorough CT. Diagnosis: BOTH of my lungs were full of blood clots, a few of them very large. I ended up in the hospital for a week. I am still frustrated and disappointed, but lucky to be alive.”
A Leading Cause of Death in America: MISDIAGNOSIS!
Over the course of a year, the total number of people who will die because they were misdiagnosed in a hospital emergency room is around 250,000.
Let that sink in for more than a moment. According to the CDC, the leading causes of death in the US are now:
“Heart disease: 696,962
Cancer: 602,350
COVID-19: 350,831
Accidents (unintentional injuries): 200,955
Stroke (cerebrovascular diseases): 160,264
Chronic lower respiratory diseases: 152,657
Alzheimer’s disease: 134,242
Diabetes: 102,188
Influenza and pneumonia: 53,544″
If the AHRQ numbers are correct, diagnostic mistakes in emergency departments are the fourth leading cause of death in America. Please note that the CDC does not list medical errors of any kind as a leading cause of death. Hmmmm, wonder why that is?
Why Are Patients Misdiagnosed in Hospitals?
Diagnosis is one of the most fundamental skills a medical student is supposed to master and then hone as a resident and practicing physician. We assume that all those arduous years of training have prepared doctors to figure out exactly why we are having symptoms. How well do they do at this essential task?
We were shocked to learn a few years ago that the answer to this crucial question is not great. Even worse, it is a third rail issue. Researchers have generally steered clear of this controversial topic. Professors in medical schools, hospital administrators and government regulators have pretty much ignored the problem.
In 2009, David Newman-Toker, MD, PhD, and his colleague Peter Pronovost, MD, PhD, blew the lid off this scandal with a groundbreaking article in the Journal of the American Medical Association titled, “Diagnostic Errors–The Next Frontier for Patient Safety.”
In this research they revealed that “an estimated 40,000 to 80,000 US hospital deaths result from misdiagnosis annually.” During a radio interview with us they subsequently confided that the number published in JAMA was probably low and a more realistic figure was more likely 100,000 hospital deaths each year from missed diagnoses.
The AHRQ’s recent systematic review was an attempt to more accurately determine the number of diagnostic errors in emergency departments. It was way higher than earlier estimates!
Misdiagnosis in the Doctor’s Office:
Keep in mind that these were misdiagnosed patients in hospitals. What about misdiagnosis in your doctor’s office?
Diagnostic errors in a primary care setting was analyzed in an article published in JAMA Internal Medicine (March 25, 2013). Until this study there was not much information about “Diagnostic errors (missed, delayed, or wrong diagnoses)” in a family practice clinic or internist’s office. Now we know the problem is worse than we imagined.
Researchers studied two large primary care practices. Site A was a large urban Veterans Affairs facility with 35 PCPs (primary care providers). Site B was a private health care system with 34 family medicine PCPs.
By tracking electronic medical records, the researchers were able to identify patients who saw a primary care provider and within two weeks either had to come back to the doctor’s office or go to an emergency room or be admitted to a hospital. They then analyzed the records of such patients to see if there had been a diagnostic error.
Of the 190 cases where diagnostic errors were discovered, most “had potential for moderate to severe harm.”
Here are the some of the common missed diagnoses:
- Kidney failure
- Pneumonia
- Cancer
- Cellulitis
- Congestive heart failure
- Compression of the spinal cord
- Urinary tract infection
- Adverse drug effect
- Heart attack or severe heart problem
When such serious conditions are missed in a primary care setting, they will be often be treated incorrectly and the outcome can be delayed recovery, severe complication or death.
According to an accompanying commentary by Drs. Newman-Toker and Makary, “more than 150,000 patients per year in the United States might have undergone misdiagnosis-related harm.” That’s in a primary care setting, not a hospital ER!
Why Are So Many People Misdiagnosed in Doctors’ Offices and Hospitals?
Why are there so many missed diagnoses? The researchers suggest that there are breakdowns in communication. Time pressure almost assuredly interferes with the process. Doctors are trained to make quick decisions based on obvious symptoms. Doing so can divert their attention from the actual cause of the problem.
These researchers documented that there were serious flaws in history taking. Patients may not have gotten to tell their stories completely. And doctors did not connect the dots accurately. Moreover, doctors do not always communicate with each other well to make sure that data from tests are transmitted appropriately.
The real shocker in this study, though, was the lack of what is called a “differential diagnosis.” In 80% of the missed diagnoses, doctors failed to follow a time-honored medical practice of considering all the possibilities and prioritizing them appropriately until the correct diagnosis was reached.
Bottom Line:
Far too many patients are misdiagnosed, either in a doctor’s office or in the hospital. These mistakes lead to inappropriate treatment and that causes “serious harm, permanent damage, immediate or inevitable death.” The authors of the study call for “patient empowerment and engagement in the diagnostic process.” We couldn’t agree more.
The authors of the article published in JAMA (Jan. 27, 2023) note that diagnostic errors are largely invisible to patients and their families and call for greater transparency. Because health care professionals are human and fallible, systems solutions offer the best way to reduce diagnostic errors efficiently. The authors suggest reducing overcrowding and utilizing checklists, machine learning, cognitive aids and better access to advanced imaging.
In our book, Top Screwups Doctors Make and How to Avoid Them, we have a list of questions to ask your doctor the next time you have a problem.
Top 10 Questions to Ask to Reduce Diagnostic Disasters:
- What are my primary concerns and symptoms?
- How confident are you about this diagnosis?
- What further tests might be helpful to improve your confidence?
- Will the test(s) you are proposing change the treatment plan in any way?
- Are there any findings or symptoms that don’t fit your diagnosis or that contradict it?
- What else could it be?
- Can you facilitate a second opinion by providing me my medical records?
- When should I expect to see my test results? Will you call with them, or will they come by mail or electronically?
- What resources can you recommend for me to learn more about my diagnosis?
- May I contact you by e-mail or text if my symptoms change or if I have an important question? If so, what is your e-mail address or cell phone number?
You can learn more about how to avoid diagnostic mistakes in our book. We provide details about the Top 10 Reasons Why Doctors Screw up Diagnoses and give you the tools you need to prevent this from happening to you or someone you love. You will also find out more about the most commonly missed diagnoses so you can be prepared. Here is a link to more information about the book.
Here are some stories below about the implications of such errors from real people.
This came from J.L.B.
“Several years ago my wife had a bad case of bronchitis. Our family doctor put her on an antibiotic. She felt better for a few weeks and then she started coughing severely again. We went back to the family doctor who is a great person and competent doctor. He was going to put her on another kind of antibiotic. I am an accountant and as an analytical person I asked him a sensible question which was ‘Why is my wife coughing so much after going through a round of antibiotic? Shouldn’t some more tests or x-rays be taken?’
“He thought over my statement for a minute and then ordered a chest x-ray. What the x-ray revealed was that my wife had a mild case of pneumonia. There was some fluid in the bottom of her lungs which showed up on the x-ray. The doctor then ordered her to stay in bed for several days and prescribed another antibiotic. Bed rest is mandatory for pneumonia whereas a person can be up and on their feet if they have bronchitis.
“If he had not discovered that she had pneumonia, she would have been on her feet and getting worse and worse. After that event whenever we went to the doctor he would ask me if I had any questions. He had a new respect for my observations/comments. He had almost made a wrong diagnosis which could have resulted in very serious situation for my wife.”
C.D.G. volunteered this story:
“My 86-year-old father went to three specialists (cardiologist, internal medicine and pulmonologist) in November complaining of shortness of breath and fatigue. All three told him he was fine. The cardiologist, who had been treating Dad for an irregular heart beat, told my sister he was concerned Dad was showing signs of dementia. The internal medicine specialist prescribed an antidepressant.
“He collapsed 10 days after seeing the pulmonologist, 20 days after seeing the cardiologist. The emergency room team said he had pneumonia and was almost at end stage congestive heart failure. He died 10 days later.
“I wrote the doctors two weeks ago asking what tests they performed to determine he was fine. Haven’t heard back and am guessing I won’t.”
The stories above reinforce the research published in JAMA Internal Medicine. Pneumonia and heart failure are frequently misdiagnosed. Don’t let it happen to those you care about. Be assertive! Ask about the “differential diagnosis” and make sure the doctor tells you what else might be causing your symptoms (besides the “obvious”).
We do not want you to become a statistic. Missed diagnosis is one of the more common causes of death in America, right up there with strokes and adverse drug reactions. It shouldn’t be. These are preventable errors. We hope you find our book helpful in avoiding medical mistakes.
Are Doctors Concerned About Patients Misdiagnosed in Hospitals?
In another study, investigators scoured the web to see what health commentators were saying about this topic (Giardina et al, Diagnosis, March 2016). They found that diagnostic errors were very rarely mentioned as a weakness of the American health care system. Nonetheless, many were able to offer personal stories of problems with diagnosis.
Researchers are working on ways to allocate responsibility for follow-up on tests (Kwan & Singh, Diagnosis, Sep. 2017). This is critical, they point out:
“to ensure that every test result is sent, received, acknowledged and acted upon without failure.”
Have you experienced any missed diagnoses? Share your story below. We hope it will empower other patients so that they can take more control over their health.
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