The contribution of diagnostic error to compensation claims is well documented internationally. To date there has been limited exploration of this in the Australian context.
Avant’s recent research examined whether there were unique factors that would lead a patient to make a complaint or compensation claim alleging diagnostic error, compared with the factors that underlie diagnostic errors more generally. Our analysis identified that the profile of diagnostic errors in our data was comparable to that of diagnostic errors reported in international research. This lack of distinguishing factors in the errors highlights the importance of developing strong doctor-patient relationships as a key to avoiding both diagnostic error and associated complaints and claims.
In this article we look at the findings from our research in more detail and consider, from the perspective of our Senior Medical Advisor Dr Walid Jammal, what this means for doctors.
Why study diagnostic error?
An accurate diagnosis is key to understanding a patient’s health concern and making appropriate care decisions. However, diagnosis is estimated to be incorrect roughly 10% of the time.(1) Although true incidence data are lacking, mounting evidence suggests diagnostic errors result in an alarming rate of patient harm and death.(2) Best estimates suggest it is one of the top ten causes of death in countries with modern healthcare systems.(1) This is perhaps unsurprising given that cancer has been reported to be the most commonly associated disease, while other potentially life threatening conditions such as cardiovascular disease and infection are also commonly reported.(3)(2)(4)
What is diagnostic error?
A widely cited definition from the Institute of Medicine states that diagnostic error is: “failure to a) establish an accurate and timely explanation of the patient’s health problem(s) or (b) communicate that explanation to the patient”.(5)
Diagnostic errors are common, appear in every healthcare setting and occur when diagnosing common and unusual conditions.(1) While it is important to acknowledge that some diagnostic errors result from factors outside of a doctor’s control, or are simply unavoidable (e.g. an undetectable malignancy, atypical presentation of a disease, incorrect information from a patient), the majority involve a doctor making a cognitive error, usually several types.(1)(5)(6)
Diagnostic error in complaints and claims
The magnitude of the issue is mirrored in the national and international literature reporting the leading contribution diagnostic error makes to compensation claims.(7)(8)(9)
Our recent analysis of approximately 2000 complaints to regulators (complaints) and 600 civil claims (compensation claims) supports these findings. We analysed matters against doctors, including all complaints to regulators and compensation claims that incurred a cost. All matters were closed between July 16 - June 17. Diagnostic error was the second most common allegation for complaints (17%) and compensation claims (27%). The contribution to compensation claims against general practitioners and physicians was particularly high; understandable given the scope of their work (Figure 1).
Figure 1. Percentage of diagnostic error related complaints and compensation claims, by specialty group
Reflecting the literature on diagnostic error, the most common principal diagnosis associated with these matters was malignant neoplasm, both overall (20% of matters) and for each of the main specialty groups (Figure 2). Diseases of the circulatory system were also among the top three overall. The third in the top 3 did not involve a disease, but a broad ICD-10 category of ‘injury, poisoning and certain other consequences of external causes’ (e.g. fractures, sprains and open wounds).
Figure 2. Percentage of diagnostic error related complaints and compensation claims with a principal diagnosis of malignant neoplasm, by specialty group.
Note: Caution should be taken with the above results for surgeons, as the sample size was small (n=48).
Our analysis also highlighted the seriousness of injuries seen in diagnostic error claims. In almost half (46%) of all matters where a doctor’s actions allegedly resulted in serious permanent physical injury or death, diagnostic error was alleged to be the cause. This rate was higher than all other types of allegation. For general practitioners, the rate was particularly high (Figure 3).
Figure 3. Primary allegation in complaints and compensation claims involving serious permanent physical injury or death of the patient, by specialty group
Note: Caution should be taken with the above results for surgeons, as the sample size was small (n=25).
Further analysis revealed that the most common underlying cause of alleged diagnostic errors was a failure to diagnose or delayed diagnosis during the initial assessment period (54% of matters). Other matters involved failed or delayed diagnosis at a different stage of care, or misdiagnosis.
Looking more closely, we found that one in 10 matters about diagnostic error involved an allegation of failure to diagnose or delayed diagnosis of a malignant neoplasm during the initial assessment stage. This scenario was a leading cause of diagnostic error matters overall (10%) and for general practitioners (12% of matters), physicians (8%) and surgeons (10%).
Factors that motivate a patient to complain
While the nature of diagnostic errors in our analysis reflects diagnostic errors more generally, only a small proportion of them end in complaints or compensation claims. A variety of factors can influence a patient to lodge a complaint or compensation claim against a doctor; not limited to the more obvious reasons like serious physical injury.
A patient who feels they have a poor relationship with their doctor, or has issues with their doctor’s manner or communication style, will be more likely to make a formal complaint or claim.(10)(11) This is seen in our data where along with the principal allegation, an additional allegation relating to a doctor’s communication or manner is recorded in approximately one quarter of all matters.
What this means for doctors
"Making a correct diagnosis remains to me, as a doctor, a quintessential sign of my clinical competency. Yet despite all the technological advances that surround us all, making a correct diagnosis remains a challenging task. I am constantly aware of the possibility of making a diagnostic error. The more experienced I become, the more I realise that there are no shortcuts. Every step of the iterative process involved in reaching a correct diagnosis requires my constant attention. I am constantly learning and adapting. I am learning to listen better to patients. In a complex medical world, I am realising that I am no longer what I was taught to be: a “lone ranger”. I am constantly trying to instil team work, trust, and collaboration into the way I work. Examining and understanding the way I think, my cognitive processes, and what factors influence my reasoning, have helped me improve. But most importantly, errors I have made have taught me to make the patient the most important part of the team. I have learnt that constantly adapting, communicating, managing expectations, and maintaining a good relationship with the patient are the most crucial part of helping me avoid errors and their associated complaints and claims."
Dr Walid Jammal, Senior Medical Advisor, Advocacy, Avant
In their publication Diagnostic Error: Learning Resource for Clinicians, the Clinical Excellence Commission help to translate this knowledge into action, by challenging doctors to pick five things from the following list to improve diagnostic quality in their practice:(1)
- Be reflective. Take a diagnostic ‘time out’
- Listen, really listen, to your patients and their caregivers
- Learn the causes of cognitive error and how to avoid pitfalls
- Don’t trust your intuition – Always construct a differential diagnosis
- Take advantage of second opinions
- Use diagnosis-specific decision support resources: DXplain, Isabel, VisualDx, checklists
- Make the patient your partner in diagnosis: Ensure they know how to get back to you if symptoms change or persist
- Ensure all ordered diagnostic tests and consults are completed and that you know the results; Designate a surrogate to review test results if you plan to be away
- Speak directly with the staff providing you with diagnostic test results: Radiologists, pathologists, and clinical pathologists. If you aren’t sure of the most appropriate diagnostic strategy, ask, or use online test-ordering advice
- Empower your colleagues to let you know if they become aware that a diagnosis you made has changed
View our short videos for practical advice from international expert, Dr Mark Graber on reducing the frequency of diagnostic errors and improving patient safety.
You can also view the webinar in its entirety to obtain CPD points.
Expert advice whenever you need it
Visit our website, or for immediate advice, call our Medico-legal Advisory Service (MLAS) on 1800 128 268, 24/7 in emergencies.
- Sydney. Clinical Excellence Commission. Diagnostic Error: Learning Resource for Clinicians. Sydney: Clinical Excellence Commission; 2015
- Graber ML. The incidence of diagnostic error in medicine. BMJ Qual Saf. 2013 Jun; 22:ii21–ii27.
- Schiff GD, Hasan O, Kim S et al. Diagnostic Error in Medicine: Analysis of 583 Physician-Reported Errors. Arch Intern Med. 2009 Nov; 169(20):1881-1887.
- Geneva. World Health Organization. Diagnostic Errors: Technical Series on Safer Primary Care. Geneva: WHO; 2016
- Washington, DC . National Academies of Sciences, Engineering, and Medicine, Institute of Medicine. Improving Diagnosis in Health Care. Washington, DC: The National Academies Press; 2015
- Jammal W, Lewis N. Cognitive bias and failure to diagnose: when you need to 'think slow'. Medicine Today. 2017 Sep;18(9):65-67.
- Wallace E, Lowry J, Smith SM, Fahey T. The epidemiology of malpractice claims in primary care: a systematic review.BMJ Open. 2013 3(6).
- Schaffer AC, Jena AB, Seabury SA, et al. Rates and Characteristics of Paid Malpractice Claims Among US Physicians by Specialty, 1992-2014. JAMA Intern Med. 2017 May;177(5):710-718.
- Canberra. Australian Institute of Health and Welfare. Australia's medical indemnity claims 2012-2013; Safety and quality of healthcare series no. 15. Canberra: AIHW; 2014
- Oyebode F. Clinical Errors and Medical Negligence. Med Princ Pract. 2013 Jun;22(4):323-333.
- Roter D. The Patient-Physician Relationship and its Implications for Malpractice Litigation. J. Health Care L. & Pol'y. 2006; 9(2);304-314.
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