Diagnostic Errors Carry a Steep Price

Michael Cohen felt something wrong with his chest and made an appointment to get it checked out with his primary care physician. His doctor suspected acid reflux, and ordered a chest X-ray. 

Cohen never heard back from the doctor to discuss the results, and the problem resolved with anti-reflux medication. But two years later, Cohen wound up in a hospital emergency room with severe chest pain. A new X-ray showed a mass in his lung that subsequently turned out to be lung cancer. 

After inquiring with his primary care doctor, Cohen learned that the original X-ray showed a mass on his lung, which had grown in the intervening 30 months. “My doctor never communicated the original radiology report to me, nor acted on the report either,” says Cohen, who underwent surgery to remove the mass only to see the cancer return a few years later. Since then, he has received near continuous chemotherapy to keep the cancer at bay. 

The experience might be remarkable considering Cohen, who has since moved to Utah, is a practicing M.D., and pathology professor at the University of Utah. The reality, though, is diagnostic errors are all too common. Though poorly documented and studied, a recent Institute of Medicine Report that Cohen helped author along with other national patient safety experts, estimates "most people will experience at least one diagnostic error in their lifetime, sometimes with devastating consequences." 

Diagnostic mistakes happen daily, asserts the report, “Improving Diagnosis in Health Care.” No health care setting is immune. And yet these errors have never been adequately studied—a most “distressing” finding, said John Ball of the American College of Physicians at a press conference to share the report’s results. Ball chaired the National Academy of Medicine committee that did the analysis. 

The report is part of a series of patient safety investigations that started with publication in 1999 of “To Err is Human,” a seminal study that estimated 44,000 to 98,000 Americans die from preventable medical errors each year. This latest installment underscores the importance of provider-patient communication for improving the quality and safety of health care. 

It’s a strategy Cohen whole-heartedly embraces as someone who knows firsthand the severe consequences of poorly coordinated care. Communication is not a one-way exchange, though, he says. It needs to be ongoing and open. 

Getting the right diagnosis is vital, because it largely dictates the rest of a person’s care. Studies show they are the main source of paid malpractice claims, and are almost twice as likely to result in death than other medical mistakes. 

The IOM proposed few solutions. But just admitting there’s a problem, being transparent about diagnostic errors, is an important first step, Cohen says. “We want to learn from our mistakes to identify true diagnostic errors, and near misses, and bring these to light in a culture that facilitates improvement but isn’t punitive.”

By: Phil Sahm

Phil Sahm is a Science Writer for University of Utah Health Sciences