Diagnostic Errors in Hospitalized Adults Who Died or Were Transferred to Intensive Care

Abstract

Importance: Diagnostic errors contribute to patient harm, though few data exist to describe their prevalence or underlying causes among medical inpatients.

Objective: To determine the prevalence, underlying cause, and harms of diagnostic errors among hospitalized adults transferred to an intensive care unit (ICU) or who died.

Design, setting, and participants: Retrospective cohort study conducted at 29 academic medical centers in the US in a random sample of adults hospitalized with general medical conditions and who were transferred to an ICU, died, or both from January 1 to December 31, 2019. Each record was reviewed by 2 trained clinicians to determine whether a diagnostic error occurred (ie, missed or delayed diagnosis), identify diagnostic process faults, and classify harms. Multivariable models estimated association between process faults and diagnostic error. Opportunity for diagnostic error reduction associated with each fault was estimated using the adjusted proportion attributable fraction (aPAF). Data analysis was performed from April through September 2023.

Main outcomes and measures: Whether or not a diagnostic error took place, the frequency of underlying causes of errors, and harms associated with those errors.

Results: Of 2428 patient records at 29 hospitals that underwent review (mean [SD] patient age, 63.9 [17.0] years; 1107 [45.6%] female and 1321 male individuals [54.4%]), 550 patients (23.0%; 95% CI, 20.9%-25.3%) had experienced a diagnostic error. Errors were judged to have contributed to temporary harm, permanent harm, or death in 436 patients (17.8%; 95% CI, 15.9%-19.8%); among the 1863 patients who died, diagnostic error was judged to have contributed to death in 121 (6.6%; 95% CI, 5.3%-8.2%). In multivariable models examining process faults associated with any diagnostic error, patient assessment problems (aPAF, 21.4%; 95% CI, 16.4%-26.4%) and problems with test ordering and interpretation (aPAF, 19.9%; 95% CI, 14.7%-25.1%) had the highest opportunity to reduce diagnostic errors; similar ranking was seen in multivariable models examining harmful diagnostic errors.

Conclusions and relevance: In this cohort study, diagnostic errors in hospitalized adults who died or were transferred to the ICU were common and associated with patient harm. Problems with choosing and interpreting tests and the processes involved with clinician assessment are high-priority areas for improvement efforts.

Figure 1.. Patient Identification, Selection, and Review Processes

Patients could be excluded for more than 1 reason. CMS indicates Centers for Medicare & Medicaid Services; ICU, intensive care unit.

Figure 2.. DEER Process Fault Dimensions: Prevalence, Adjusted Associations With Diagnostic Errors, and Adjusted Attributable Fractions (aAFs) (N = 2428)

Multivariable models included adjustment for sex, race, ethnicity, admission source, admission status, insurance (primary payer); the following comorbidities: congestive heart failure, complicated hypertension, kidney failure, chronic pulmonary disease, complicated diabetes, fluid and electrolyte disorders, liver disease, metastatic cancer, obesity, alcohol use disorder, substance use disorder; a primary diagnosis of sepsis, stroke, or myocardial infarction; whether patient preferences affected the diagnostic process; and whether the patient had a primary care physician, housing challenges, communication challenges, or altered mental status. Adjusted rate ratios (aRRs) were estimated using Cox proportional hazard models, with the time variable set to unity for all individuals, using the Breslow method for ties. Adjusted attributable fractions were computed using logistic regression models. DEER indicates the Diagnostic Error Evaluation and Research framework.