Cases & Commentaries

Diagnosing Diagnostic Mistakes

Spotlight Case
Commentary By Robert McNutt, MD; Richard Abrams, MD; Scott Hasler, MD

Learning Objectives

  • Understand the biases that may
    contribute to overcalling medical errors
  • Describe the impact of considering the
    clinical spectrum of disease presentations or alternative diagnoses
    on assessment of error
  • Appreciate the challenges inherent in
    assigning the label of “missed diagnosis” to a clinical

The Commentary

In medicine, there is often confusion about which
harms are reducible and which inevitable. Judgments about
appropriateness are often based on incomplete, indirect, or
unreliable data. At present, the knowledge base in safety research
cannot provide definitive correlations between clinical decisions,
the systems of delivery, and purported adverse events.

Given these deficiencies, we believe
that—both in the literature and in
practice—“error” is being overcalled. Some
classifications consider the terms “missed diagnosis”
or “delayed diagnosis” as merely adverse events (and
not errors), reserving the designation of “error” for
those missed or delayed diagnoses that are preventable. We think
that the designation of “missed or delayed diagnoses”
is fraught with ambiguity and unclear definitions. Applying these
terms requires the use of judgment, and we believe that these
judgments are often flawed, or at least debatable.

Error identification schemes often judge error as
emanating from simple chains of events that can be understood and
easily reconfigured. But, uncovering cause and effect is more
complex than identifying simple relationships—redundancy and
codependency abound.(1,2)
The dependencies among risk factors in safety research (both
decisions and systems) are particularly likely to require rigorous
scientific methods to determine cause and effect, because
dependencies are so prevalent in complex systems.

Identifying diagnostic mistakes is especially
difficult. As part of a grant from the Agency for Healthcare
Research and Quality (AHRQ), our group has been working on
evaluating diagnostic decisions to determine how many truly
represent “errors.” As part of this research, we
evaluated cases from the archives of AHRQ WebM&M to determine
whether we come to the same conclusion as the case discussants (and
presumably the editors): namely, that a submitted case represents a
preventable medical mistake. We have found that we often disagree
with the attribution of patient harm to errors. In this commentary,
we will review two cases from the WebM&M archives to illustrate
some potential sources of ambiguity that influence the attribution
of error.

Issue #1

Overcalling error due to evaluation of a case
with knowledge of the patient’s outcome (hindsight bias);
especially in the face of no gold standard for diagnosis.

Case—Doctor, Don't Treat Thyself

A 50-year-old radiologist presented with
shortness of breath and interpreted his own chest x-ray as being
“consistent” with pneumonia. Later the patient died of
a myocardial infarction and pulmonary edema. Several radiologists
reviewed the chest x-ray (after the outcome) and reported it
“consistent” with pulmonary edema. The case was deemed
by the discussant to “dramatically and tragically”
illustrate a diagnostic mistake.

We don’t believe that this case represents
a preventable mistake or even a missed diagnosis, since, in our
view, useful classification systems for preventable mistakes cannot
include cases with no gold standard for the diagnosis. We recognize
that this stringent standard, if widely applied, may suggest that
diagnostic error cannot be defined by outcomes of care.

By “gold standard” we mean a high
level of agreement about the criteria for diagnosis, such that
different observers would agree when applying the criteria. The
lack of agreement among observers trying to discriminate pneumonia
from heart failure on a chest x-ray of a dyspneic patient is
partially due to ambiguity in the criteria for making these
diagnoses. For example, the overall accuracy of the evaluation of
dyspnea is imprecise.(3)
Studies suggest that variation between observers when assessing
patients accounts for at least some of the inaccuracy in assessing
the value of classic signs and symptoms of heart failure.(4) In
one study, two university radiologists could identify chest x-ray
signs of pneumonia with only “fair to good” reliability
and were especially poor in defining the pattern of

Given the ambiguity in the diagnostic criteria
for heart failure and pneumonia and the imperfect agreement for
interpreting the chest x-ray, radiologists who know a
patient’s outcome interpret chest x-ray findings differently
than radiologists who are unaware of the ultimate outcome
(hindsight bias).(6,7)
In the case at hand, it is irrelevant that the first radiologist
was the patient; this discrepancy could occur between any two
radiologists. Subjective criteria will be influenced by who, when,
where, and how judgments are made.

The best way to minimize the impact of hindsight
bias is to ignore the outcome. The outcome (good or bad) for a
patient should not be revealed when trying to classify diagnostic
mistakes. Evaluation of an adverse event should be done by an
independent review panel following a structured, evidence-based
assessment of the processes—not the outcomes—of

Issue #2

Overcalling error due to failure to consider
the spectrum of clinical presentations and the consequences of
competing diagnoses.

Case—Crushing Chest Pain: A Missed Opportunity

A 62-year-old woman is admitted with crushing
chest pain and treated for possible myocardial infarction (MI). She
later dies of an aortic dissection (AD). The case, when discussed
on AHRQ WebM&M, was felt by the discussant to be a diagnostic

This case does not represent a missed diagnosis
or a preventable error for several reasons. First, clinical
presentations of a particular disease vary. Some dissecting
aneurysms can be noted by the most casual of observations (i.e.,
wide and expanding mediastinum in a patient known to have an
aneurysm), while some can be missed even after utmost scrutiny. In
our judgment, this case is an example of the latter. The discussant
claimed that the diagnosis was missed due in part to failure to
note a small calcium deposit on the chest x-ray (again noted in
hindsight), but the AHRQ WebM&M presentation had to magnify the
finding on the radiograph in order to render it visible to readers
(Figure). It is not clear how many observers, blinded
to the outcome, would miss this finding, but surely some would.
Before this case could be classified as an error, we would need to
show that trained observers, blinded to the outcome, would see the
radiologic finding and would, correctly and earlier in the
patient’s course, have made the diagnosis of dissecting
Second, the quality of the literature addressing various diagnostic
tests for AD is poor. Reports of the accuracy of diagnostic tests
are biased by retrospective reviews of charts of patients known to
have suffered from AD.(10-12)
Certainly those reports do not include patients requiring a
magnified view of a small abnormality.

In addition to the failure to consider the
spectrum of disease presentations, another reason for mislabeling
is the failure to consider the consequences of competing diseases
as the cause of a patient’s complaints. The diagnostic
process is not static; instead, it is a fluid refinement of
possible diagnoses.(13)
Yet potential cases of missed or delayed diagnoses often come to
light when a “surprise” diagnosis is found—one
different from the diagnosis being pursued and/or treated. This
surprise diagnosis is too often assumed to be “missed.”
This case illustrates that missing one diagnosis may be preferred
to missing another.

The dissecting aneurysm case is one in which (i)
several serious diseases may explain the patient’s complaint;
and (ii) empiric treatment of one may increase the chance of
death in another; and (iii) the value of diagnostic tests to
differentiate one disease from another is unknown or poorly
studied. For example, MI, acute coronary syndrome (ACS), pulmonary
embolus (PE), and AD are all in the differential diagnosis of the
patient’s complaints. These diseases take varying times to
diagnose and have markedly different probabilities of occurrence,
and each has different risks and benefits for diagnostic testing or
delaying effective therapies.

The result of these uncertainties may require a
physician to act on one disease to the detriment of another. For
example, a workup for AD may delay life-saving anticoagulant
therapy for someone who is having ACS. Since ACS is more common
than AD in most clinical situations, more harm than good may come
from an overzealous attempt to not miss AD.

While this tradeoff has not been formally
analyzed, we believe that such an analysis would conclude that AD
represents a virtually insoluble diagnostic problem for many of its
clinical presentations. To illustrate why, we performed a
“back of the envelope” decision analysis. In it, we
assumed that the ratio of AD:ACS for patients presenting with chest
pain is at most 1:250.(14-16)
We further assumed that if we found AD without delay (through the
use of a perfectly accurate test), the patient’s life would
be saved. We then assumed that a delay in anticoagulant therapy for
ACS that occurs while assessing all patients for AD would lead to a
1% increase in death or myocardial infarction.(17,18) In summary, we assumed a 100% marginal improvement
for making the diagnosis of AD and a 1% marginal improvement for
early therapy for patients with ACS. These assumptions bias the
analysis for making the diagnosis of AD (since, in real life, some
people do die even when the diagnosis is made promptly). Given
these assumptions, a vigorous search for AD in all patients that
delayed anticoagulation for possible ACS would kill or cause MI in
2-3 patients with ACS for every patient with AD whose life would be
saved. We use this threshold model of decision making as our
criterion standard in diagnosis care evaluations.(19) This standard requires that explicit, evidence-based
tradeoffs for competing diagnoses be considered before asserting
that a preventable diagnostic mistake may have occurred.


Hindsight bias, especially in the face of
subjective criteria for definitions of disease and test
interpretation, a failure to consider the ambiguity imposed by the
spectrum of clinical presentations for a single disease, and the
complex trade-offs between competing causes of a patient’s
complaints, makes classifying errors in diagnosis precarious. We
believe that any attempt to determine cause and effect
(preventability) must incorporate these factors (Table). We believe that diagnostic error may be a
misused concept when outcomes of care are considered, and that
clinical practitioners rarely fully appreciate their own
limitations in analyzing their diagnostic reasoning, especially
once the case’s outcomes are revealed.(20) Instead, error classification may need to shift to
processes of care, asking such question as: Are the diagnosticians
seeking a reasonable differential diagnosis? Do diagnostic plans
incorporate the risk/benefit of finding one diagnosis rather than
another? Were the appropriate tests ordered for the differential
diagnosis list?

Research on diagnostic errors may be stifled
until we have an accurate method to assign cause-and-effect
relationships to our decisions, systems of care, and adverse
events, supported by a robust taxonomy of diagnostic improvement
opportunities. When cases are deemed to be diagnostic errors in
journal articles (including AHRQ WebM&M) and elsewhere, it is
worth considering contrary opinions, focused particularly on
whether one or more of the four hypothesized classification
conundrums has occurred (Table). Such an interchange may hasten the development
of a useful classification scheme for diagnostic mistakes.

McNutt, MD
Professor and Associate Chair, Department of Medicine
Associate Director, Medical Informatics and Patient Safety
Rush University Medical Center, Chicago, IL

Richard Abrams, MD
Associate Professor and Program Director, Department of
Co-Chair, Patient Safety Committee
Rush University Medical Center, Chicago, IL

Scott Hasler, MD
Assistant Professor and Associate Program Director, Department of
Rush University Medical Center, Chicago, IL

Faculty Disclosure: Drs. McNutt,
Abrams, and Hasler have declared that neither they, nor any
immediate member of their families, has a financial arrangement or
other relationship with the manufacturers of any commercial
products discussed in this continuing medical education activity.
In addition, they do not intend to include information or discuss
investigational or off-label use of pharmaceutical products or
medical devices.


1. McNutt RA, Abrams R, Aron DC, for the Patient
Safety Committee. Patient safety efforts should focus on medical
errors. JAMA. 2002;287:1997-2001.
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2. McNutt RA, Abrams RI. A model of medical error
based on a model of disease: interactions between adverse events,
failures, and their errors. Qual Manag Health Care.
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3. Mulrow CD, Lucey CR, Farnett LE.
Discriminating causes of dyspnea through clinical examination. J
Gen Intern Med. 1993;8:383-392.
go to PubMed

4. Badgett RG, Lucey CR, Mulrow CD. Can the
clinical examination diagnose left-sided heart failure in adults?
JAMA. 1997;277:1712-1719.
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5. Albaum MN, Hill LC, Murphy M, et al.
Interobserver reliability of the chest radiograph in
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6. Carthey J. The role of structured
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7. Lilford RJ, Mohammed MA, Braunholz D, Hofer
TP. The measurement of active errors: methodological issues. Qual
Saf Health Care. 2003;12(suppl 2):ii8-12.
go to PubMed

8. McNutt RA, Abrams R, Hasler S, et al.
Determining medical error. Three case reports. Eff Clin Pract.
go to PubMed

9. Berlin L. Defending the “missed”
radiographic diagnosis. AJR Am J Roentgenol. 2001;176:317-322.
go to PubMed

10. Klompas M. Does this patient have an acute
thoracic aortic dissection? JAMA. 2002;287:2262-2272.
go to PubMed

11. Hagan PG, Nienaber CA, Isselbacher EM, et al.
The International Registry of Acute Aortic Dissection (IRAD): new
insights into an old disease. JAMA. 2000;283:897-903.
go to PubMed

12. Moore AG, Eagle KA, Bruckman D, et al. Choice
of computed tomography, transesophageal echocardiography, magnetic
resonance imaging, and aortography in acute aortic dissection:
International Registry of Acute Aortic Dissection (IRAD). Am J
Cardiol. 2002;89:1235-1238.
go to PubMed

13. Kassirer JP, Kopelman RI. Learning Clinical
Reasoning. Baltimore, MD: Lippincott Williams & Wilkins;

14. Meszaros I, Morocz J, Szlavi J, et al.
Epidemiology and clinicopathology of aortic dissection. Chest.
go to PubMed

15. Conti A, Paladini B, Toccafondi S, et al.
Effectiveness of a multidisciplinary chest pain unit for the
assessment of coronary syndromes and risk stratification in the
Florence area. Am Heart J. 2002;144:630-635.
go to PubMed

16. Khan IA, Nair CK. Clinical, diagnostic, and
management perspectives of aortic dissection. Chest.
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17. Husted SE, Kraemmer Nielsen H, Krusell LR,
Faergeman O. Acetylsalicylic acid 100 mg and 1000 mg daily in acute
myocardial infarction suspects: a placebo-controlled trial. J
Intern Med. 1989;226:303-310.
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18. Madsen JK, Pedersen F, Amtoft A, et al.
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streptokinase and aspirin therapy. Results of ISIS-2. Ugeskr
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19. Pauker SG, Kassirer JP. The threshold
approach to clinical decision making. N Engl J Med.
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20. Kassirer JP. Our stubborn quest for
diagnostic certainty. A cause of excessive testing. N Engl J Med.
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Table. Hypothesized Classification

  • Hindsight bias—evaluation of a case with knowledge of the
  • Lack of a gold standard for the diagnosis
  • Failure to consider the spectrum of clinical presentations
  • Failure to consider competing diagnoses


Figure. Calcium
Sign Magnified in the Radiograph Presented in Crushing Chest Pain Case