Northeast Florida Medicine
Vol. 66, No. 1 2015
23
CME
• Engaging patients on multiple levels to become
“co-producers” of safer medical diagnosis practices
• Weaving “safety nets” to mitigate harm from
uncertainties and errors in diagnosis
14,15
Creating and maintaining a patient problem list can help
prevent and avoid diagnosis errors. It can ensure that each
active problem is being addressed, with reminders about
diagnoses, allergies, and unexplained findings. It is also useful
in ensuring follow-up of health maintenance. Likewise, an
up-to-date medication list, reconciled at each patient visit
(or admission) is essential for patient safety.
3
AHarris poll commissioned by theNational Patient Safety
Foundation found that one in six people had personally
experienced a medical error related to misdiagnosis.
4
Most
medical error studies find that on average, 20 percent of
errors are errors in diagnosis. They further reported that
a recent review of 53 autopsy studies found an average
rate of 23.5 percent major missed diagnoses. Selected dis-
ease-specific studies also show that substantial percentages
of patients averaging at 30 percent experienced missed or
delayed diagnoses. While the studies used different criteria
and methodologies, what emerged was compelling evidence
for the frequency and impact of diagnosis error and delay.
Physicians are frequently confronted with rapid changes
in diagnostic testing and care pathway expectations. New
imaging modalities, lab tests and testing recommendations
have been introduced, often leaving physicians confused
about what to order or how to interpret contradictory results
(from one sub-specialist to the next). If diagnosis errors are
to be avoided, physicians must be aware of the limitations
of diagnostic tests they order.
A normal mammogram in a woman with a breast lump
does not rule out the diagnosis of breast cancer, as test
sensitivity of test is only 70 to 85 percent. A recurring
theme of case reviews was failure to appreciate pitfalls in
weighing test results in the context of the patient’s pretest
disease probabilities. Local factors, such as the variation in
quality of test performance and readings, combined with
communication failures between radiology/laboratory
and ordering physicians (results reported as “positive” or
“negative,” overlooking subtleties and limitations) provide
further sources of error.
16
Active listening is an essential component of an accurate
diagnosis, and too often the physician has only partial
information, which can result in diagnostic errors. The
physician can fall victim to bias based on what he/she did
hear and as a result “went down the incorrect biased diag-
nostic pathway.”
17,18
Diagnostic Pitfalls
Errors occur when physicians are trying to make an
accurate diagnosis of a medical problem. Some closed case
reviews help us understand why errors in ascertaining the
correct diagnosis occur.
Case One:
A recent malpractice case highlights missing an early
diagnosis and causation of harm. The litigant had a family
history that included breast cancer diagnoses for two female
relatives (one was her mother) who had breast cancer in
their forties. At 33, she began getting annual screening
mammograms, which showed dense breasts. She complained
of a small palpable mass. However, no mass was seen on a
mammogram, and the diagnosis was fibrocystic changes.
No additional tests were ordered. Within six months, the
mass was enlarging, and she was diagnosed with infiltrating
ductal cancer that had advanced from a Stage I to a Stage
III. The plaintiff’s attorney made his case that, based on
her history, she should have been tested for the BRCA mu-
tation and given various treatment options. Additionally,
he noted that no ultrasounds or MRIs were done, which
possibly could have detected the cancer at an earlier treat-
able stage. According to
“The Doctor’s Practice”
magazine of
the Doctors Company, published in September 2013, “A
woman’s risk of developing breast and/or ovarian cancer
greatly increases if she inherits a BRCA1 or BRCA2 gene
mutation.
19
Widespread screening is not required because
together these mutations account for only five to 10 percent
of breast cancers. Those with the BRCA1 mutation have a
55–65 percent chance of developing breast cancer by age
70, and those with the BRCA2 mutation have a 45 percent
chance.” Women have about a two percent chance of get-
ting ovarian cancer, but if they have a BRCA2 mutation,
that risk increases to 40 to 60 percent. The following risk
factors should be assessed by the physician with actions
taken as indicated for existence:
19
• Maternal or paternal blood relatives with
breast cancer diagnosed before the age of 50
• Pancreatic, colon or thyroid cancers present
in family members
• Both breast and ovarian cancer in a patient’s family,
especially in one individual
• Women in a patient’s family with bilateral breast cancer
• Patient with Ashkenazi Jewish heritage
• A male blood relative with breast cancer
• Relative with BRCA1 or BRCA2 mutation
