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Diagnostic Errors in the Emergency Department

Key Questions Draft

Open for comment through Oct 23, 2020


The National Academy of Medicine (NAM) has called diagnostic error a "blind spot" for modern medicine and improving diagnosis a "moral, professional, and public health imperative."9 The emergency department (ED) is a known high-risk site for diagnostic error.10-15The key decisional dilemma for this evidence review is "What are the most common and significant medical diagnostic failures in the ED, and why does this happen?" The goal is to determine the following: (1) What are the most frequent signs and symptoms and clinical conditions that are associated with diagnostic errors in the ED and urgent care settings?; (2) For specific clinical conditions, what are the factors associated with diagnostic errors in the ED and urgent care settings?; (3) Are there commonalities across clinical conditions associated with diagnostic errors in the ED and urgent care settings?

Draft Key Questions

Key Question 1: What clinical conditions are associated with the greatest number of diagnostic errors and serious misdiagnosis-related harms in the ED? Prospectively analyzed subgroups will include the following:

  1. Adults (≥18yo) vs. children (<18yo)
  2. ED discharges vs. admissions
  3. Physicians vs. advanced practice providers
  4. Providers who are trained vs. not trained in emergency medicine
  5. Studies conducted in United States vs. non-United States

Key Question 2: Overall and for the clinical conditions identified from KQ1, how common are ED diagnostic errors and serious misdiagnosis-related harms?

  1. How were diagnostic errors and harms defined and identified? 
  2. How were diagnostic errors and harms categorized? 
  3. What are the most frequent clinical presenting symptoms or signs that are associated with diagnostic errors in the ED? 
  4. Are there key commonalities or differences among frequencies of ED diagnostic errors across clinical conditions? 

Key Question 3: Overall and for the clinical conditions identified from KQ1, what are the key causal factors associated with ED diagnostic errors and serious misdiagnosis-related harms?

  1. What methods were used to investigate causes? 
  2. How were causes categorized?
  3. What were the most frequent causes identified?
  4. Do different causes have differential impact on patient outcomes (harms)? 
  5. Overall and for each clinical condition: 
    1. What patient characteristics are associated with errors/harms? In particular, are there associations with age, gender, language, socioeconomic status/income, literacy, racial/ethnic characteristics? 
    2. What clinician characteristics are associated with errors/harms?
    3. What facility or health system characteristics are associated with errors/harms?
  6. Are there key commonalities or differences among causes of ED diagnostic errors across clinical conditions?

Serious misdiagnosis-related harms are defined to include death or permanent disability (NAIC scale 6–9). Clinical conditions anticipated to top the list are vascular events (stroke, myocardial infarction, venous thromboembolism, aortic aneurysm and dissection, arterial thromboembolism), infections (sepsis, meningitis and encephalitis, spinal abscess, pneumonia, endocarditis, and appendicitis), and fractures. Additional conditions that are likely relevant to a pediatric population include testicular torsion, necrotizing enterocolitis, and sudden cardiac death/arrythmias/congenital heart disease. The results of KQ1's search will inform whether any additional conditions are added to the initial list of 15 conditions for KQ2/KQ3. We will exclude specialty EDs (e.g., eye and ear) from the primary analysis.

Figure 1: Draft Analytic Framework

Figure 1 is the draft analytic framework. The framework starts with patients presenting to the emergency department. These patients receive a diagnosis, which is influenced by symptoms and signs, patient characteristics, clinical characteristics, and facility or health system characteristics. The diagnosis can either be correct or wrong. A misdiagnosis can result in either a serious harm (death or permanent disability) or a lesser harm.


PerSPEcTiF Framework 


  • From the perspective of the health system


  • In the ED


  • Diagnostic error/misdiagnosis-related harms


  • Within the environment of hospital and health systems based in the United States, Canada, UK, Western Europe, Australia/New Zealand, Taiwan, South Korea, and Japan.


  • We will include studies from 2000 to present. There will be a comparison of studies between 2000–2010 to 2011–2021.


  • List of key diseases and clinical conditions accounting for the majority of serious misdiagnosis-related harms
  • Frequency of diagnostic errors and serious misdiagnosis-related harms overall and for key clinical conditions
  • Patient, clinician, facility and health system characteristics that are associated with diagnostic errors/harms

Definition of Terms

ED = emergency department
NAM = National Academy of Medicine
SPADE = Symptom-disease Pair Analysis of Diagnostic Error


  1. Sharp AL, Baecker A, Nassery N, et al. Missed acute myocardial infarction in the emergency department-standardizing measurement of misdiagnosis-related harms using the SPADE method. Diagnosis (Berlin, Germany). 2020 Jul 23. doi: 10.1515/dx-2020-0049. PMID: 32701479.
  2. Nuzzo A, Joly F, Ronot M, et al. Normal Lactate and Unenhanced CT-Scan Result in Delayed Diagnosis of Acute Mesenteric Ischemia. The American journal of gastroenterology. 2020 Aug 26. doi: 10.14309/ajg.0000000000000836. PMID: 32852337.
  3. Nishiguchi S, Nishino K, Kitagawa I, et al. Factors associated with delayed diagnosis of infective endocarditis: A retrospective cohort study in a teaching hospital in Japan. Medicine. 2020 Jul 24;99(30):e21418. doi: 10.1097/md.0000000000021418. PMID: 32791760.
  4. Mansella G, Keil C, Nickel CH, et al. Delayed Diagnosis in Pulmonary Embolism: Frequency, Patient Characteristics, and Outcome. Respiration; international review of thoracic diseases. 2020;99(7):589-97. doi: 10.1159/000508396. PMID: 32694258.
  5. Kannari L, Marttila E, Toivari M, et al. Paediatric mandibular fracture-a diagnostic challenge? International journal of oral and maxillofacial surgery. 2020 Jul 14. doi: 10.1016/j.ijom.2020.06.008. PMID: 32680807.
  6. Gold JAW, Jackson BR, Benedict K. Possible Diagnostic Delays and Missed Prevention Opportunities in Pneumocystis Pneumonia Patients Without HIV: Analysis of Commercial Insurance Claims Data-United States, 2011-2015. Open forum infectious diseases. 2020 Jul;7(7):ofaa255. doi: 10.1093/ofid/ofaa255. PMID: 32704515.
  7. Watari T, Tokuda Y, Mitsuhashi S, et al. Factors and impact of physicians' diagnostic errors in malpractice claims in Japan. PloS one. 2020;15(8):e0237145. doi: 10.1371/journal.pone.0237145. PMID: 32745150.
  8. Tarnutzer AA, Lee SH, Robinson KA, et al. ED misdiagnosis of cerebrovascular events in the era of modern neuroimaging: A meta-analysis. Neurology. 2017 Apr 11;88(15):1468-77. doi: 10.1212/wnl.0000000000003814. PMID: 28356464.
  9. National Academies of Science, Engineering, and Medicine. Improving Diagnosis in Health Care. Washington, DC: The National Academies Press; 2015. Accessed on February 12, 2020.
  10. Hussain F, Cooper A, Carson-Stevens A, et al. Diagnostic error in the emergency department: learning from national patient safety incident report analysis. BMC Emerg Med. 2019 Dec 4;19(1):77. doi: 10.1186/s12873-019-0289-3. PMID: 31801474.
  11. Newman-Toker DE, Schaffer AC, Yu-Moe CW, et al. Serious misdiagnosis-related harms in malpractice claims: The "Big Three"—vascular events, infections, and cancers. Diagnosis (Berlin, Germany). 2019 Aug 27;6(3):227-40. doi: 10.1515/dx-2019-0019. PMID: 31535832.
  12. Brown TW, McCarthy ML, Kelen GD, et al. An epidemiologic study of closed emergency department malpractice claims in a national database of physician malpractice insurers. Acad Emerg Med. 2010 May;17(5):553-60. doi: 10.1111/j.1553-2712.2010.00729.x. PMID: 20536812.
  13. Kachalia A, Gandhi TK, Puopolo AL, et al. Missed and delayed diagnoses in the emergency department: a study of closed malpractice claims from 4 liability insurers. Ann Emerg Med. 2007 Feb;49(2):196-205. doi: 10.1016/j.annemergmed.2006.06.035. PMID: 16997424.
  14. Selbst SM, Friedman MJ, Singh SB. Epidemiology and etiology of malpractice lawsuits involving children in US emergency departments and urgent care centers. Pediatric emergency care. 2005 Mar;21(3):165-9. PMID: 15744194.
  15. Trautlein JJ, Lambert RL, Miller J. Malpractice in the emergency department--review of 200 cases. Ann Emerg Med. 1984 Sep;13(9 Pt 1):709-11. doi: 10.1016/s0196-0644(84)80733-7. PMID: 6465652.