Misdiagnosis Mistakes in Emergency Rooms Happen All Too Often

By Jonathan Petty | January 17, 2023

Patients in Richmond have a right to trust that if they need to go to their nearest emergency room, the ER doctors will make the correct diagnosis and provide appropriate treatment. A misdiagnosis can cause a patient to suffer until the accurate diagnosis is made. A misdiagnosis can also mean that opportunity for necessary treatment is lost because the delay causes irreversible harm. In some cases, a misdiagnosis can be fatal.

Misdiagnosis Mistakes in Emergency Rooms Happen All Too Often

A recent study shows how often diagnostic mistakes happen in the emergency room. The US Department of Health and Human Services (DHHS) study examined 279 emergency department (ED) studies published over two decades. The DHHS study “applied standard definitions for diagnostic errors, misdiagnosis-related harms (adverse events), and serious harms (permanent disability or death). Preventability was determined by original study authors or differences in harms across groups.”

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Per their findings:

  • About 1 in 18 patients nationwide (5.7 percent of the patients studied) were diagnosed incorrectly.
  • The study found that there were 7.4 million misdiagnosis mistakes every year. About 1/3 of the patients suffered harm that could have been prevented; about 370,000 patients are permanently disabled by, or died as a result of, misdiagnosis. The study revealed that these misdiagnosis rates in emergency departments were similar to the rate of diagnostic errors in primary care and inpatient hospital settings.
  • There was a significant rate of diagnostic error across emergency departments (EDs) in different types of hospitals. While error rates were generally lower in academic/teaching hospitals than in community hospitals, it is not known if other factors such as increased availability and increased use of diagnostic technologies were factors.
  • Most ED diagnostic errors were cognitive errors (meaning errors in decision-making by the provider), with the study noting:
    • “Malpractice claims associated with serious misdiagnosis-related harms involved failures of clinical assessment, reasoning, or decision making in about 90 percent of cases.” [emphasis ours]
    • “Key process failures were errors in diagnostic assessment, test ordering, and test interpretation. Most often these were attributed to inadequate knowledge, skills, or reasoning, particularly in ‘atypical’ or otherwise subtle case presentations.”
  • The strongest predictors of emergency room diagnostic error were “individual case factors that increased the cognitive challenge of identifying the underlying disorder, with nonspecific, mild, transient, or ‘atypical’ symptoms being the most frequent.”
  • Finally, “Estimated preventable adverse event rates were as follows: any harm severity (2.0%, 95% CI 1.0 to 3.6), any serious harms (0.3%, PR 0.1 to 0.7), and deaths (0.2%, PR 0.1 to 0.4).”

The role of race, age, and sex/gender in misdiagnosis

The diagnostic mistakes in the ER varied across different demographic groups. For example, “younger age increases risk of missed stroke 6.7-fold, while older age increases risk of missed appendicitis.”

Females and non-whites “were often associated with important (20–30%) increases in misdiagnosis risk; although these disparities were inconsistently demonstrated across studies, being a woman or a racial or ethnic minority was generally not found to be ‘protective’ against misdiagnosis (i.e., was neutral at best).” In other words, the study seems to indicate that more data is needed, but the general trend is that women and people of color were more likely to be misdiagnosed than white males. This finding is not new; multiple studies, collated in an issue of Prevention Magazine, have found that woman are more likely to be misdiagnosed than men, and Black women are most likely to experience “diagnostic delay” for breast cancer.

Which illnesses are most likely to be improperly diagnosed?

According to the findings of the DHHS study, the leading illnesses that were improperly diagnosed were:

  1. Stroke
  2. Myocardial infarction (heart attack)
  3. Aortic aneurysm/dissection
  4. Spinal cord compression/injury
  5. Venous thromboembolism (DVT)
  6. Meningitis and encephalitis
  7. Sepsis (tied with meningitis and encephalitis)
  8. Lung cancer
  9. Traumatic brain injury and traumatic intracranial hemorrhage
  10. Arterial thromboembolism
  11. Spinal and intracranial abscess
  12. Cardiac arrhythmia
  13. Pneumonia
  14. Gastrointestinal perforation and rupture
  15. Intestinal obstruction

The top five leading causes accounted for 39 % of serious diagnostic errors. About 2/3 of all diagnostic mistakes are attributable to 15 medical conditions. Researchers noted “Stroke, the top serious harm-producing disease, is missed an estimated 17% of the time.”

According to CNN’s analysis, stroke was often diagnosed incorrectly as dizziness or vertigo. About two in five patients with dizziness and vertigo were not properly diagnosed for a stroke.

The position of leading ED physician groups

The US DHS study was described as “misleading” and “incomplete” by 10 of the country’s leading emergency physician groups, including the American College of Emergency Physicians and the American Board of Emergency Medicine. These groups say that while improvement is always possible, the misdiagnosis designation is based on a “misunderstanding of the aim of emergency medicine, which is to focus on the acute and immediate situation.” The letter written by the group states that emergency care:

…is rightfully less concerned with diagnosis and more concerned with appropriate stabilization and referral for future evaluation of a symptom complex. Rather than relying on the post-hoc judgment of preventable diagnostic errors, emergency physicians seek to explore proper stabilization of the patient and admission to the hospital or referral for definitive care. It is the very nature of [emergency medicine] that some patients will be dispositioned without the final diagnosis being evident.

The group also noted that some of the studies included EDs from other countries. The study did include an analysis of EDs in Canada, Spain, and Switzerland.

Suggestions for improving emergency department patient diagnosis

The study concluded that while ED error rates are low, the number of patients who are affected is large. Improvement should be made even though not all diagnostic mistakes are preventable. These can include better bedside diagnostic processes that target the most common types of ER misdiagnosis mistakes and key diseases. Other policy changes that ED should consider include:

  • “Standardizing measurement and research results reporting to maximize comparability of measures of diagnostic error and misdiagnosis-related harms;”
  • Creating a National Diagnostic Performance Dashboard to monitor performance; and
  • Using research funding, public accountability, payment reforms, and other policy measures to address the need for accurate diagnoses of patients in the emergency room.

At Phelan Petty, we understand when diagnostic errors are preventable and what steps your doctors should have taken to prevent them. We work with our network of doctors to analyze what diagnostic tests were ordered, how your physical examination was conducted, what questions were asked, and what other steps your ER doctor should have taken. Our Richmond-based medical malpractice lawyers demand compensation for all your medical bills, your pain and suffering, lost income, physical injuries, and other damages Virginia law permits.

To discuss your right to hold negligent emergency doctors and hospitals accountable, call our medical malpractice lawyers or use our contact form to schedule a free consultation. We are based in Richmond and serve all of Virginia.

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