Misdiagnosis: We know when, but do we know why?

A recent patient safety study has revealed that at least 28 percent of patients who died in an intensive care unit (ICU) had been misdiagnosed at least once in the ICU before death. Unfortunately, questions about why this occurs have not yet been answered fully.

Part of the reason we don’t yet know “why” is that patient safety efforts have focused on non-fatal risks, such as infections, delays in treatment, falls and other events that may cause further injury or illness, but are not necessarily fatal.

However, we do know the types of fatal misdiagnoses that are most likely to occur. A study by the Johns Hopkins Armstrong Institute for Patient Safety and Quality showed that one-third of misdiagnoses involved myocardial infarction, pulmonary embolism, pneumonia and aspergillosis. And in eight percent of these, the misdiagnosis could be shown to be a direct cause of death.

Many have speculated about and studied the problems that can result in misdiagnoses in hospital ICU and emergency room (ER) settings. Among the most commonly cited are language barriers and lack of translators, overworked physicians, undertrained doctors at the resident and intern level, failure to maintain diagnostic equipment (or lack of the equipment altogether), and inadequate staffing levels.

However, because we do know the conditions that are most likely to be misdiagnosed in an ICU or ER setting, patient safety experts can begin developing protocols to overcome some of the problems that interfere with correct diagnoses. .

Source: Clinical Advisor, “ICU misdiagnoses claim as many as 40,500 lives per year,” Sep. 18, 2012.