What is the appropriate course of action if a colleague misses a diagnosis (dx)?

When a Colleague Misses a Diagnosis: Professional and Patient Safety Response

If you discover a colleague has missed a diagnosis, you must immediately prioritize patient safety by ensuring the correct diagnosis is communicated to the patient and appropriate treatment is initiated, while simultaneously documenting the error through your institution's voluntary reporting system to enable systems-level learning and prevention. 1, 2

Immediate Actions: Patient Safety First

Direct Patient Care

• Contact the patient immediately to communicate the correct diagnosis and initiate appropriate treatment, as delays in diagnosis account for the largest category of high-severity malpractice claims and can result in serious harm or death in 48-59% of cases 2, 3
• Document your clinical reasoning clearly, including why the original diagnosis was incorrect and what findings led to the correct diagnosis, as failure to follow established diagnostic protocols can constitute breach of standard of care 4
• Implement appropriate treatment urgently for time-sensitive conditions (e.g., pulmonary embolism, acute coronary syndrome, cancer), as "time is myocardium and time is outcomes" in many missed diagnoses 1, 4

Communication with the Colleague

• Engage in direct physician-to-physician communication to discuss the case, as this is recommended when diagnostic concerns are identified 1
• Approach the conversation as a learning opportunity rather than punitive, recognizing that diagnostic errors typically result from multiple breakdowns (median of 3 process breakdowns per error) and are rarely due to a single individual's failure 2, 3
• Share digital images or test results via secure channels to facilitate understanding of the diagnostic discrepancy 1

Institutional Reporting and Systems Learning

Error Reporting Requirements

• Report the diagnostic error through your institution's voluntary, blame-free reporting system, as this practice is well-established in diagnostic radiology with discrepancy meetings and should be standard across all specialties 1
• Participate in root cause analysis to identify whether this was an isolated active error or reflects latent systems errors that could affect multiple patients 1
• Document the specific process breakdowns involved, which most commonly include: failure to order appropriate diagnostic tests (55-58%), inadequate history/physical examination (42-47%), incorrect test interpretation (37%), and failure to arrange appropriate follow-up (45%) 2, 5, 3

Contributing Factors to Address

The error likely involved multiple contributing factors that should be identified 2, 3:

• Cognitive factors (present in 79-96% of errors): failures in clinical judgment, pattern recognition, or knowledge gaps
• System factors: excessive workload (23%), inadequate supervision (30%), poor handoffs (20-24%)
• Patient-related factors (34-46%): atypical presentations, communication barriers
• Inadequate follow-up systems (15%): lack of tracking for pending test results or referrals

Preventing Future Errors: Institutional Interventions

Implement Structured Diagnostic Approaches

• Establish regular discrepancy meetings where diagnostic errors are reviewed in a non-punitive environment to share learning across the team 1
• Develop and use diagnostic checklists for high-risk conditions that are commonly missed, including pneumonia (6.7%), heart failure (5.7%), acute renal failure (5.3%), cancer (5.3%), and pulmonary embolism 4, 5
• Apply validated clinical prediction rules (e.g., Wells criteria for PE, HEART score for ACS) to standardize risk stratification and reduce cognitive bias 1, 4

Address Cognitive Biases

• Practice metacognition (thinking about thinking) to recognize when you're using System 1 thinking (pattern recognition, mental shortcuts) versus System 2 thinking (deliberate, analytical reasoning) 1
• Implement debiasing strategies including: pausing before finalizing diagnoses, considering alternative diagnoses systematically, and avoiding confirmation bias 1, 6
• Use objective rather than subjective tests when possible, and apply age-adjusted reference ranges (e.g., D-dimer thresholds in older patients) 1, 4

Common Pitfalls to Avoid

Documentation Errors

• Never alter the original medical record or attempt to cover up the missed diagnosis, as this creates legal liability and prevents systems learning 4
• Do document your clinical reasoning for the corrected diagnosis, including clear rationale for why the original diagnosis was incorrect 4

Communication Failures

• Avoid "normalization of deviance" where errors become tolerated without systematic efforts to prevent recurrence 1
• Don't assume the colleague was negligent – recognize that 68 unique diagnoses were missed across studies, involving common conditions that any clinician could miss under certain circumstances 5
• Ensure proper handoffs when transferring care, as inadequate handoffs contribute to 20-24% of diagnostic errors 2, 3

Systems Issues

• Don't treat this as an isolated incident – the median diagnostic error involves 3 process breakdowns and 3 contributing factors, indicating systems-level problems 2, 3
• Recognize that most errors occur during the patient-practitioner encounter (79%), particularly in history-taking (56%), physical examination (47%), and ordering appropriate tests (57%), suggesting need for better clinical decision support 5

Legal and Professional Considerations

Standard of Care

• Failure to follow established diagnostic protocols constitutes breach of standard of care, with serious legal implications 4
• The prevalence of harmful diagnostic errors in hospitalized patients is approximately 0.7%, corresponding to ~250,000 harmful errors yearly in the US, making this a significant patient safety and medicolegal concern 7
• Documentation of clinical decision-making is essential, especially when diagnostic uncertainty exists or alternative diagnoses are being considered 4

Quality Improvement Focus

• Target the 14 diagnoses that account for >50% of all diagnostic errors, including malignancy (11%), pulmonary embolism (9.6%), pneumonia, heart failure, and acute renal failure 7, 5
• Improve basic diagnostic processes rather than focusing solely on rare diseases, as the wide range of common diagnoses being missed indicates fundamental process problems 7, 5