HIDDEN IN PLAIN SIGHT: Exposing the Drivers of Diagnostic Error
A Three-Part Series:
Part One: The Emergency Department
Published: September 2024
This white paper is the first in a three-part series that explores diagnostic error in three different care settings: ambulatory, emergency department, and hospital. It is based on an analysis of five years of closed medical malpractice events (2019-2023).
While the emergency department (ED) is the second-most frequent location for diagnostic error allegations, we decided to make it the first location examined in this series due to the large number of high-acuity patients and the fast-paced environment.
Included in the report is a self-assessment tool (to identify crucial ED best practices that address contributing factors identified in our data) and five key steps to mitigate risk in the ED.
Key Takeaways
- 26% of all malpractice events closed during the five-year period studied involved diagnostic error (this includes all locations, not just the three addressed in this series).
- 28% of all diagnostic error events occurred in the ED. The fast-paced, high-acuity environment of the ED increases the potential for known vulnerabilities and errors in the diagnostic process to occur.
- 67% of ED events involved one or more element of clinical decision-making, most notably failure to obtain an adequate history and physical (46%), followed by test interpretation (27%), and test ordering (17%).
