Common Generic Lessons Learned (“Take-Home Messages”) Described by Physicians Following a Diagnostic Error
| Generic Lesson | Description | Example | Patient-Specific Lessons |
|---|---|---|---|
| Consider specific disease in specific circumstances | Be alert to the possibility of disease(s) X under circumstance(s) Y. Anyone with symptom(s) X should have disease(s) Y ruled out or at least considered. | Missed severe hyponatremia, sodium 115 mEq/L, in a woman presenting with anxiety: “Include electrolyte imbalance in the differential diagnosis of anxiety.” | 37 (15) |
| Look beyond the initial diagnosis | Look beyond the obvious. Although we always attempt to find one diagnosis that explains all the findings, we should never assume that only one condition explains everything. | Missed pulmonary embolus in a woman presenting with asthma exacerbation: “Do not assume the obvious.” | 26 (10) |
| Be alert to atypical presentations | Be alert to nonclassic or atypical presentation of diseases that do not follow the normal pattern. Remember that disease X can masquerade as disease Y. Do not rule out serious disease solely on the basis of age or a negative test result or a negative element of the history or physical exam. Be aware of blunted symptoms in the elderly. | Missed myocardial infarction in a man presenting with heartburn after running out of omeprazole: “Always consider atypical presentations with anyone with any kind of chest pain even though patient is convinced otherwise!” | 24 (9) |
| Be more aggressive with diagnostic testing | Be more aggressive with diagnosis in specific circumstances, but also maintain selectivity when ordering tests. | Missed severe pulmonary hypertension in woman presenting with dyspnea and hypoxia: “Consider testing for pulmonary hypertension earlier [rather] than later.” | 19 (8) |
| Reconsider diagnosis if patient follows unexpected course | Reassess and repeat the evaluation if the patient does not respond as expected or the course is not as expected or not everything fits. | Missed pancreatic cancer in an elderly man with weakness: “When something doesn't make sense, keep searching! . . . persistent weakness despite treating UTI.” | 18 (7) |
| Consider uncommon conditions | Missed neurosyphilis in an elderly woman presenting with delirium and confusion: “We were always taught that syphilis was the ‘great imitator’ and to check for it but it had been a long time since I had seen anything but a false positive. Should still be considered in acute neuropsychiatric presentations. Just because it isn't common does not mean a diagnosis should not be considered!” | 15 (6) | |
| Do complete physical exam | Do a better physical exam in general and in specific circumstances. | Missed ovarian cancer in a woman presenting with pelvic discomfort: “I did a lousy pelvic exam. Be methodical, do not guess.” | 15 (6) |
| Broaden the differential in general | General statement to broaden the differential diagnosis. | Missed ischemic bowel in a woman with diarrhea and fever: “I learned to be more diligent and methodical in broadening my differential.” | 14 (6) |
| Arrange more reliable, specific follow-up | Arrange better follow-up in specific circumstances; provide return parameters; take a more active role in arranging follow-up; physician should initiate follow-up, such as a phone call, not just leave it up to the patient. | Missed endometrial cancer in a woman with abnormal uterine bleeding: “Call patients on the phone and don't leave a follow up plan to the next visit. They can move!” | 11 (4) |
| Consider “don't-miss” diagnoses | Rule out the worst-case scenario. | Missed coronary disease in a man presenting with respiratory distress: “If there is a possibility of a disease with a high morbidity, I should at least do an initial screening.” | 8 (3) |
| Other* | 67 (26) | ||
| Total† | 254 (100) |