Table 4.

Common Generic Lessons Learned (“Take-Home Messages”) Described by Physicians Following a Diagnostic Error

Generic LessonDescriptionExamplePatient-Specific Lessons
Consider specific disease in specific circumstancesBe 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 diagnosisLook 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 presentationsBe 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 testingBe 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 courseReassess 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 conditionsMissed 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 examDo 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 generalGeneral 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-upArrange 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” diagnosesRule 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)
Total254 (100)
  • Values provided as n (%).

  • * Encompasses 14 other lessons.

  • The 202 physicians described up to 3 lessons per error, for a total of 254 lessons.

  • UTI, urinary tract infection.