Diagnostic errors in the emergency department: A systematic review (15 December 2022)

Summary

Diagnostic errors are a known patient safety concern across all clinical settings, including the emergency department (ED). The authors from the John Hopkins University conducted a systematic review to determine the most frequent diseases and clinical presentations associated with diagnostic errors (and resulting harms) in the ED, measured error and harm frequency, as well as assessing causal factors.

Content

Although estimated ED error rates are low (and comparable to those found in other clinical settings), the number of patients potentially impacted is large. Not all diagnostic errors or harms are preventable, but wide variability in diagnostic error rates across diseases, symptoms, and hospitals suggests improvement is possible. With 130 million U.S. ED visits, estimated rates for diagnostic error (5.7%), misdiagnosis-related harms (2.0%), and serious misdiagnosis-related harms (0.3%) could translate to more than 7 million errors, 2.5 million harms, and 350,000 patients suffering potentially preventable permanent disability or death. Over two-thirds of serious harms are attributable to just 15 diseases and linked to cognitive errors, particularly in cases with "atypical" manifestations.

Scalable solutions to enhance bedside diagnostic processes are needed, and these should target the most commonly misdiagnosed clinical presentations of key diseases causing serious harms. New studies should confirm overall rates are representative of current U.S.-based ED practice and focus on identified evidence gaps (errors among common diseases with lower-severity harms, paediatric ED errors and harms, dynamic systems factors such as overcrowding, and false positives).

Policy changes to consider based on this review include:

1. Standardising measurement and research results reporting to maximise comparability of measures of diagnostic error and misdiagnosis-related harms.
2. Creating a National Diagnostic Performance Dashboard to track performance
3. Using multiple policy levers (e.g., research funding, public accountability, payment reforms) to facilitate the rapid development and deployment of solutions to address this critically important patient safety concern.