Errors in clinical diagnosis: a narrative review

Abstract

Diagnostic errors are often caused by cognitive biases and sometimes by other cognitive errors, which are driven by factors specific to clinicians, patients, diseases, and health care systems. An experienced clinician diagnoses routine cases intuitively, effortlessly, and automatically through non-analytic reasoning and uses deliberate, cognitively effortful analytic reasoning to diagnose atypical or complicated clinical cases. However, diagnostic errors can never be completely avoided. To minimize the frequency of diagnostic errors, it is advisable to rely on multiple sources of information including the clinician's personal experience, expert opinion, principals of statistics, evidence-based data, and well-designed algorithms and guidelines, if available. It is also important to frequently engage in thoughtful, reflective, and metacognitive practices that can serve to strengthen the clinician's diagnostic skills, with a consequent reduction in the risk of diagnostic error. The purpose of this narrative review was to highlight certain factors that influence the genesis of diagnostic errors. Understanding the dynamic, adaptive, and complex interactions among these factors may assist clinicians, managers of health care systems, and public health policy makers in formulating strategies and guidelines aimed at reducing the incidence and prevalence of the phenomenon of clinical diagnostic error, which poses a public health hazard.

Keywords: Judgment; analytic reasoning; cognitive bias; decision-making; diagnostic error; medical uncertainty; non-analytic reasoning.

Figure 1.

Factors influencing the diagnostic process. Complex interactions among clinician-, patient-, disease-, system-, and environment-specific factors, some of which are characterized by elements of uncertainty, are key determinants of clinical decision-making. The greater the uncertainty, the greater the likelihood of generating risky or inappropriate clinical decisions, and this is complicated by dealing with difficult or demanding patients. Adapted from Croskerry (2018).

Figure 2.

The diagnostic process. The information obtained from the clinical history, physical examination, diagnostic tests, referrals, and consultations is analyzed and interpreted. This information is then used to formulate a working diagnosis through clinical judgment and reasoning. After the diagnosis has been finalized, it is explained to the patient and treatment options are discussed. The outcome of the treatment choice must be followed-up, and if needed, the initial diagnosis and treatment should be revised. Clinical diagnosis is a dynamic, adaptive, multifactorial process. Diagnostic errors can be brought about by any faulty operative factor driving this process. To minimize the adverse health consequences of diagnostic errors, it is essential to follow-up patients in a timely manner, particularly those with an uncertain initial diagnosis, and promptly revise the diagnosis if needed.^,