Prevalence and Causes of Diagnostic Errors in Hospitalized Patients Under Investigation for COVID-19

Abstract

Background The COVID-19 pandemic required clinicians to care for a disease with evolving characteristics while also adhering to care changes (e.g., physical distancing practices) that might lead to diagnostic errors (DEs). Objective To determine the frequency of DEs and their causes among patients hospitalized under investigation (PUI) for COVID-19. Design Retrospective cohort. Setting Eight medical centers affiliated with the Hospital Medicine ReEngineering Network (HOMERuN). Target population Adults hospitalized under investigation (PUI) for COVID-19 infection between February and July 2020. Measurements We randomly selected up to 8 cases per site per month for review, with each case reviewed by two clinicians to determine whether a DE (defined as a missed or delayed diagnosis) occurred, and whether any diagnostic process faults took place. We used bivariable statistics to compare patients with and without DE and multivariable models to determine which process faults or patient factors were associated with DEs. Results Two hundred and fifty-seven patient charts underwent review, of which 36 (14%) had a diagnostic error. Patients with and without DE were statistically similar in terms of socioeconomic factors, comorbidities, risk factors for COVID-19, and COVID-19 test turnaround time and eventual positivity. Most common diagnostic process faults contributing to DE were problems with clinical assessment, testing choices, history taking, and physical examination (all p < 0.01). Diagnostic process faults associated with policies and procedures related to COVID-19 were not associated with DE risk. Fourteen patients (35.9% of patients with errors and 5.4% overall) suffered harm or death due to diagnostic error. Limitations Results are limited by available documentation and do not capture communication between providers and patients. Conclusion Among PUI patients, DEs were common and not associated with pandemic-related care changes, suggesting the importance of more general diagnostic process gaps in error propagation.

Inappropriate Diagnosis of Pneumonia Among Hospitalized Adults

“…Why might physicians inaccurately diagnose CAP? First, because CAP is common, physicians are at high risk for cognitive biases such as availability bias (ie, the tendency to make decisions based on information that comes most readily to mind) . Second, CAP symptoms are nonspecific and may overlap with other cardiopulmonary diseases (eg, congestive heart failure exacerbation), making diagnosis difficult.…”

“…First, because CAP is common, physicians are at high risk for cognitive biases such as availability bias (ie, the tendency to make decisions based on information that comes most readily to mind). 23 , 24 Second, CAP symptoms are nonspecific and may overlap with other cardiopulmonary diseases (eg, congestive heart failure exacerbation), making diagnosis difficult. Given poor outcomes associated with CAP, in the setting of uncertainty, health care professionals may favor overtreatment rather than potentially missing a CAP diagnosis.…”

Diagnostic Errors in Hospitalized Adults Who Died or Were Transferred to Intensive Care

“…All cases in this study were reviewed by 2 physicians trained in error adjudications, with extensive oversight and quality-checking steps in place . Use of 2 physician reviews is a common approach in patient safety research and a method we used in past research examining readmissions and diagnostic errors . Both physician reviewers needed to agree to the entirety of the adjudication assessment for the adjudication to be finalized.…”