Missed or delayed diagnosis

Missed or delayed diagnosis

Summary:

Next steps for missed or delayed diagnosis.

SegmentsDiagnosis & treatmentFactsheets
22 / 04 / 2016

Avant claims data indicates that 60% of diagnostic errors are related to a missed or delayed diagnosis.

Consider this scenario. You have been treating a 35-year-old woman for four years. During that time, she has had classic migraine symptoms, which usually respond to ergotamine and analgesics. In the last year, the symptoms have been more frequent and prophylaxis with Deseril has been helpful.

She again presents with the usual symptoms but has noticed some face numbness and a more frequent pattern of occurrence. A CT scan shows a 4cm meningioma in the right temporal area which clearly has been there for a long time.

At some time you may face a similar diagnostic challenge. It may be less dramatic or more serious. “Could this have been picked up earlier?” is an obvious question the patient will put to you – and one which requires an answer. Your response will set the scene for the ongoing relationship and sometimes influence how the patient responds to the delay in diagnosis.

 

Handling the situation

1. Personally tell the patient - Depending on the urgency of the diagnosis, contact the patient to inform them of the unexpected finding and its implications. A personal telephone call to set up a face-to-face conversation is the most appropriate course, rather than delegation to another member of the practice.

2. Obtain advice - If necessary, contact a specialist for advice on the likely treatment required and the impact of the delayed diagnosis so you are prepared to answer the patient’s questions when you meet with them.

3. Explain the situation - Have a face-to-face discussion with your patient about the new findings. Use open disclosure, say how sorry you are about the unexpected news. Explain what treatment may be necessary.

4. Arrange management of the patient and immediate treatment - Preferably, arrange these through a phone call while the patient is present; do not just give the patient a referral letter and ask them to arrange the follow-up consultation.

5. Maintain contact with the patient - Enquire periodically about the patient’s progress to help them cope with the feelings about the diagnosis or any possible delays. Expressions of personal concern and interest in what has occurred (such as enquiring about a recent admission to hospital or other treatment) are part of good ongoing care and will assist in the ongoing doctor–patient relationship.

6. Offer ongoing care - When the crisis period has passed, the patient may or may not wish to continue under your care. If the patient requests referral to a new doctor, facilitate the transfer and offer to provide the new doctor with the patient’s medical records.

7. Consider the cause of the delayed diagnosis - kneejerk reaction after such an experience would be to overinvestigate every patient presenting with a headache. It is more sensible to consider your thoughts and decisions in relation to the management of the patient and develop objective criteria for the management of common clinical problems.

8. Review systems - If the delay was caused or contributed to by a systems error, such as follow-up failure or misfiling of pathology or X-ray reports, review your systems to prevent a recurrence. Avant can advise you about current practice standards for investigation tracking and follow-up systems.

9. Change and inform - We recommend you seek advice from Avant before taking this step to avoid making any admissions of liability. Telling the patient about the steps you have taken to minimise the risk of a repeat of this situation can reassure them that some learning has come from what happened. This can be achieved through following open disclosure practices.

10. Notify Avant about the incident - As soon as possible after you become aware of the incident let Avant know. If you receive a letter of complaint from the patient or their representative, do not reply without first obtaining advice from Avant.

11. Consider cancelling your fee - Avoid sending accounts and reminders where these will inflame the situation. It is better to forego a fee than risk offending the patient. Patients will often forgive human error but they never forgive error combined with perceived greed or arrogance. Not sending a bill is not an admission of liability.

 

What if another doctor is responsible for the misdiagnosis and you have made the correct diagnosis?

When discussing the diagnosis and its implications, stick to the facts. You only have one side of the history and as such, it is better to avoid any implied or stated criticism about the doctor(s) who may have been responsible for previous diagnosis. It is not uncommon for a legal claim or complaint to be pursued by a patient after throwaway comments by the second doctor, which were not intended to be a criticism. Remain professional and objective during these exchanges.

If, at a later date, the patient’s solicitor seeks a report in the investigation of a compensation claim, keep the report objective and avoid criticism. Contact Avant if you are unsure what is required.

As a guide, do what you would expect the other doctor to do if the roles were reversed. This might include informing the other doctor of the correct diagnosis and, if the patient agrees, offering to send the patient back to that doctor so they have an opportunity to explain.

All too often, the first inkling of an error or patient dissatisfaction is when a doctor receives a writ or a solicitor’s “letter before action” which proposes negligence proceedings.

 

Best practice

  • Consider open disclosure, which would generally include an apology saying, “I am/We are sorry”.
  • Refer the patient immediately for urgent treatment, if required.
  • Ensure clear documentation of events in the patient’s records.
  • Maintain interest in the patient’s progress.
  • Avoid sending accounts for incorrect treatment.
  • Avoid unnecessary or derogatory comments about your colleagues.
  • Notify Avant about adverse incidents and complaints. If in doubt about whether to notify, contact Avant anyway.

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