A team of experts from the Johns Hopkins Armstrong Institute for Patient Safety and Quality has determined that 28% of patients in a recent study – more than one in four – had at least one missed diagnosis at the time of death in the intensive care unit (ICU).

“Our study shows that misdiagnosis is alarmingly common in the acute care setting,” Bradford Winters, MD, PhD, of Johns Hopkins University School of Medicine, and colleagues reported in BMJ Quality & Safety. “To date, there’s been very little research to determine root causes or effective interventions.”

Less lethal patient safety risks have received greater attention, Winters pointed out. So he and colleagues examined 31 studies that included 5,863 autopsies in a wide range of ICU types.

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Among 8% of patients, the diagnostic error was serious enough that it may have caused or directly contributed to the patient’s death, and had doctors been aware of the proper diagnosis, the treatment likely would have been different.

Infections and vascular issues, including myocardial infarction and stroke, were implicated in three quarters of these fatal flaws. About one-third of all illnesses that clinicians failed to detect were attributable to one of four conditions: myocardial infarction, pulmonary embolism, pneumonia and aspergillosis.

”Future studies should seek to prospectively measure the prevalence and impact of diagnostic errors and potential strategies to reduce them,” The researchers wrote.


  1. Winters B et al. BMJ Qual Saf. DOI:10.1136/bmjqs-2012-000803