Measuring Diagnostic Error: A Review of Patient Complaints


Michael H Kanter, MD; Lawrence D Lurvey, MD; Kerry C Litman, MD;
Ronald K Loo, MD; William Strull, MD; Mimi Hugh, MPH, MA;
Maverick Au

Abstracts from the Kaiser Permanente 2019 National Quality Conference

From Southern California

Background: Diagnostic error, as defined by the Institute of Medicine’s 3 key elements (failure to establish a timely, accurate diagnosis that is appropriately communicated to the patient), is increasingly recognized as an important contributor to delayed diagnosis and can be a source of serious medical harm, yet measuring diagnostic error can be a challenge. Although claims data can give an indication of missed diagnoses long after the fact, measuring diagnostic error from the patient’s perspective provides insights and opportunities to identify and potentially to mitigate diagnostic issues at an earlier stage. Member Services is the first portal to collect patient complaints; nonclinical staff summarize and code each complaint; 7-code description categories fit the definition of diagnostic error and contain significant volume to allow useful analysis.
Methods: From the 7-code description categories that fit the definition of diagnostic error, 158 cases were randomly selected for review from 2 perspectives: 1) the patient—via review of the intake summary, and 2) the physician—via review of the patient’s medical record. These cases were evaluated for any of the 3 elements of diagnostic error in the intake summary and in the patient’s medical record. Ten physicians reviewed and assessed the cases using a uniform evaluation tool to document their findings. Tabulated results determined whether the diagnostic-related codes of complaints were accurate indicators of potential diagnostic error.
Results: From the patient’s perspective, 2 categories, Diagnosis Delayed/Missed/Incorrect and Test Results Delay, yielded high specificity (81% and 93%) of diagnostic errors. Other categories had low volumes or did not meet the definition of diagnostic error. From the physician’s perspective, diagnostic error was identified at much lower rates on the basis of documentation in the medical record of accurate and timely diagnosis and communication to the patient. In the routine review of complaints, the majority had potential quality issues (94% and 63%) and were forwarded to the Quality Department for further investigation, but only a few cases had quality issues that led to peer review scoring of a minor or significant opportunity for improvement; most had no quality issues. Perception of the quality of communication may explain this difference; it may be assumed by the physician that adequate communication occurred if documented in the medical record, whereas patients may not have felt they were adequately informed.
Discussion: The addition of communication to the definition of diagnostic error has shed light on a common problem. The patient’s perspective should be the gold standard regarding adequate communication, and whether the diagnosis was well understood, its implications, and a plan of care. Adequacy of communication may be documented in the medical record, but may not convey the patient’s true perceptions. In addition, the Institute of Medicine definition does not define timely; the patient’s perspective should be used in determining timeliness, because it is less subject to interobserver variation from physician reviewers. Identifying diagnostic error rates from patient complaint data may be a useful way to measure diagnostic error over time in a more rapid manner than current methods, allowing more timely investigations and system improvements to reduce future harm.

Abstracts from the Kaiser Permanente 2019 National Quality Conference


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