Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2021 Dec;30(12):977-985.
doi: 10.1136/bmjqs-2020-012594. Epub 2021 Jun 14.

Incidence, origins and avoidable harm of missed opportunities in diagnosis: longitudinal patient record review in 21 English general practices

Sudeh Cheraghi-Sohi  1   2 , Fiona Holland  2   3 , Hardeep Singh  4 , Avril Danczak  5 , Aneez Esmail  2 , Rebecca Lauren Morris  1 , Nicola Small  2 , Richard Williams  1 , Carl de Wet  6 , Stephen M Campbell  1   2 , David Reeves  7   3
Affiliations

Incidence, origins and avoidable harm of missed opportunities in diagnosis: longitudinal patient record review in 21 English general practices

Sudeh Cheraghi-Sohi et al. BMJ Qual Saf. 2021 Dec.

Abstract

Background: Diagnostic error is a global patient safety priority.

Objectives: To estimate the incidence, origins and avoidable harm of diagnostic errors in English general practice. Diagnostic errors were defined as missed opportunities to make a correct or timely diagnosis based on the evidence available (missed diagnostic opportunities, MDOs).

Method: Retrospective medical record reviews identified MDOs in 21 general practices. In each practice, two trained general practitioner reviewers independently conducted case note reviews on 100 randomly selected adult consultations performed during 2013-2014. Consultations where either reviewer identified an MDO were jointly reviewed.

Results: Across 2057 unique consultations, reviewers agreed that an MDO was possible, likely or certain in 89 cases or 4.3% (95% CI 3.6% to 5.2%) of reviewed consultations. Inter-reviewer agreement was higher than most comparable studies (Fleiss' kappa=0.63). Sixty-four MDOs (72%) had two or more contributing process breakdowns. Breakdowns involved problems in the patient-practitioner encounter such as history taking, examination or ordering tests (main or secondary factor in 61 (68%) cases), performance and interpretation of diagnostic tests (31; 35%) and follow-up and tracking of diagnostic information (43; 48%). 37% of MDOs were rated as resulting in moderate to severe avoidable patient harm.

Conclusions: Although MDOs occurred in fewer than 5% of the investigated consultations, the high numbers of primary care contacts nationally suggest that several million patients are potentially at risk of avoidable harm from MDOs each year. Causes of MDOs were frequently multifactorial, suggesting the need for development and evaluation of multipronged interventions, along with policy changes to support them.

Keywords: adverse events; diagnostic errors; epidemiology and detection; general practice; patient safety.

PubMed Disclaimer

Conflict of interest statement

Competing interests: None declared.

Comment in

References

    1. Panesar SS, deSilva D, Carson-Stevens A, et al. How safe is primary care? A systematic review. BMJ Qual Saf 2016;25:544–53. 10.1136/bmjqs-2015-004178 - DOI - PubMed
    1. England N . General practice forward view, 2016.
    1. Newman-Toker DE, McDonald KM, Meltzer DO. How much diagnostic safety can we afford, and how should we decide? A health economics perspective. BMJ Qual Saf 2013;22 Suppl 2:ii11–20. 10.1136/bmjqs-2012-001616 - DOI - PMC - PubMed
    1. Cresswell KM, Panesar SS, Salvilla SA, et al. Global research priorities to better understand the burden of iatrogenic harm in primary care: an international Delphi exercise. PLoS Med 2013;10:e1001554. 10.1371/journal.pmed.1001554 - DOI - PMC - PubMed
    1. National Academies of Sciences E, and Medicine . Improving diagnosis in health care. Washington DC, 2015.

Publication types