Original Investigation
January 8, 2024
Diagnostic Errors in Hospitalized Adults Who Died or Were Transferred to Intensive Care
Andrew D. Auerbach, Tiffany M. Lee, Colin C. Hubbard, et al
JAMA Intern Med. Published online January 8, 2024. doi:10.1001/jamainternmed.2023.7347
Question How often do diagnostic errors happen in adult patients who are transferred to the intensive care unit (ICU) or die in the hospital, what causes the errors, and what are the associated harms?
Findings In this cohort study of 2428 patient records, a missed or delayed diagnosis took place in 23%, with 17% of these errors causing temporary or permanent harm to patients. The underlying diagnostic process problems with greatest effect sizes associated with diagnostic errors, and which might be an initial focus for safety improvement efforts, were faults in testing and clinical assessment.
Meaning Among hospitalized adults transferred to the ICU or who died in the hospital, diagnostic errors were common, harmful, and had underlying causes, which can be used to design future interventions.
Abstract
Importance Diagnostic errors contribute to patient harm, though few data exist to describe their prevalence or underlying causes among medical inpatients.
Objective To determine the prevalence, underlying cause, and harms of diagnostic errors among hospitalized adults transferred to an intensive care unit (ICU) or who died.
Design, Setting, and Participants Retrospective cohort study conducted at 29 academic medical centers in the US in a random sample of adults hospitalized with general medical conditions and who were transferred to an ICU, died, or both from January 1 to December 31, 2019. Each record was reviewed by 2 trained clinicians to determine whether a diagnostic error occurred (ie, missed or delayed diagnosis), identify diagnostic process faults, and classify harms. Multivariable models estimated association between process faults and diagnostic error. Opportunity for diagnostic error reduction associated with each fault was estimated using the adjusted proportion attributable fraction (aPAF). Data analysis was performed from April through September 2023.
Main Outcomes and Measures Whether or not a diagnostic error took place, the frequency of underlying causes of errors, and harms associated with those errors.
Results Of 2428 patient records at 29 hospitals that underwent review (mean [SD] patient age, 63.9 [17.0] years; 1107 [45.6%] female and 1321 male individuals [54.4%]), 550 patients (23.0%; 95% CI, 20.9%-25.3%) had experienced a diagnostic error. Errors were judged to have contributed to temporary harm, permanent harm, or death in 436 patients (17.8%; 95% CI, 15.9%-19.8%); among the 1863 patients who died, diagnostic error was judged to have contributed to death in 121 (6.6%; 95% CI, 5.3%-8.2%). In multivariable models examining process faults associated with any diagnostic error, patient assessment problems (aPAF, 21.4%; 95% CI, 16.4%-26.4%) and problems with test ordering and interpretation (aPAF, 19.9%; 95% CI, 14.7%-25.1%) had the highest opportunity to reduce diagnostic errors; similar ranking was seen in multivariable models examining harmful diagnostic errors.
Conclusions and Relevance In this cohort study, diagnostic errors in hospitalized adults who died or were transferred to the ICU were common and associated with patient harm. Problems with choosing and interpreting tests and the processes involved with clinician assessment are high-priority areas for improvement efforts.
