Diagnostic Errors in the Emergency Department: A Systematic Review

 What is your stroke hospital misdiagnosis rate on strokes?

Have they prevented these problems from happening?

Auckland man dies from stroke after being misdiagnosed with a migraine

 

Factors Associated with Stroke Misdiagnosis in the Emergency Department: A Retrospective Case-Control Study

 

Factors Associated With Misdiagnosis of Acute Stroke in Young Adults

 

Pediatric Stroke Often Misdiagnosed, Treatment Delayed

 

Younger Stroke Patients Often Misdiagnosed

 

 Among 821 consecutive patients admitted to an acute stroke unit, the initial diagnosis of stroke proved incorrect in 108 (13%)

 

The latest here:

Diagnostic Errors in the Emergency Department: A Systematic Review

• Overall diagnostic accuracy in the emergency department (ED) is high, but some patients receive an incorrect diagnosis (~5.7%). Some of these patients suffer an adverse event because of the incorrect diagnosis (~2.0%), and some of these adverse events are serious (~0.3%). This translates to about 1 in 18 ED patients receiving an incorrect diagnosis, 1 in 50 suffering an adverse event, and 1 in 350 suffering permanent disability or death. These rates are comparable to those seen in primary care and hospital inpatient care.
• We estimate that among 130 million emergency department (ED) visits per year in the United States that 7.4 million (5.7%) patients are misdiagnosed, 2.6 million (2.0%) suffer an adverse event as a result, and about 370,000 (0.3%) suffer serious harms from diagnostic error. Put in terms of an average ED with 25,000 visits annually and average diagnostic performance, each year this would be over 1,400 diagnostic errors, 500 diagnostic adverse events, and 75 serious harms, including 50 deaths per ED. Although overall error and harm rates are derived from three smaller studies conducted outside the United States (in Canada, Spain, and Switzerland, with combined n=1,758), study methods were prospective and rigorous. All three were conducted at university hospitals, and, for the two studies used to estimate harms, about 92 percent of clinicians under study at those institutions had full training or formal certification in emergency medicine.
• Five conditions (#1 stroke, #2 myocardial infarction, #3 aortic aneurysm/dissection, #4 spinal cord compression/injury, #5 venous thromboembolism) account for 39 percent of serious misdiagnosis-related harms, and the top 15 conditions account for 68 percent. Variation in diagnostic error rates by disease are striking (range 1.5% for myocardial infarction to 56% for spinal abscess, with the other thirteen falling between 10% and 36%). Stroke, the top serious harm-producing disease, is missed an estimated 17% of the time. Among these 15 diseases, myocardial infarction is the only one with false negative rates near zero (1.5%), well below the estimated average rate across all diseases (5.7%).
• For a given disease, nonspecific or atypical symptoms increase the likelihood of error. For stroke, dizziness or vertigo increases the odds of misdiagnosis 14-fold over motor symptoms (those with dizziness and vertigo are missed initially 40% of the time).
• Variation in diagnostic error rates across demographic groups is present and sometimes fairly large in magnitude. The effect of age is heterogeneous and disease-specific (e.g., younger age increases risk of missed stroke 6.7-fold, while older age increases risk of missed appendicitis). Female sex and non-White race were often associated with important (20–30%) increases in misdiagnosis risk; although these disparities were inconsistently demonstrated across studies, being a woman or a racial or ethnic minority was generally not found to be "protective" against misdiagnosis (i.e., was neutral at best).
• Variation in diagnostic error rates across specific hospital EDs is wide. Methods of measuring diagnostic errors in the ED are highly variable. However, even when similar methods are used, measured diagnostic error rates vary up to 100-fold across hospitals. In individual studies, missed cases varied by hospital for subarachnoid hemorrhage (0% to 100%), myocardial infarction (0% to 29%), and appendicitis (1% to 16%). Error rates are usually found to be lower in academic/teaching hospitals, but it is unknown if this is an effect of increased availability/intensive use of diagnostic technologies or other factors.
• Root causes of ED diagnostic errors were mostly cognitive errors linked to the process of bedside diagnosis. Malpractice claims associated with serious misdiagnosis-related harms involved failures of clinical assessment, reasoning, or decision making in about 90 percent of cases. Similar findings were seen in incident report data. These issues are not unique to the ED—they are seen across clinical settings, regardless of study method.
• The strongest, most consistent predictors of ED diagnostic error were individual case factors that increased the cognitive challenge of identifying the underlying disorder, with nonspecific, mild, transient, or "atypical" symptoms being the most frequent.
• Our findings are tempered by limitations in the underlying evidence base, including issues related to data sources, measurement methods, and causal relationships. Nevertheless, overall diagnostic error and misdiagnosis-related harm rates are consistent with what has been found in other clinical settings (e.g., primary care and inpatient).