Most diagnostic errors identified in a study that focused on primary-care settings were related to process breakdowns that occurred in the patient-practitioner clinical encounter.

“Preventive interventions should target common contributory factors across diagnoses, especially those that involve data gathering and synthesis in the patient-practitioner encounter,” concluded Hardeep Singh, MD, MPH, and colleagues in JAMA Internal Medicine.

To determine the types of diseases missed and the diagnostic processes involved in cases of confirmed diagnostic errors and to determine whether record reviews could shed light on potential contributory factors, Singh’s team reviewed medical records of diagnostic errors detected in 
primary-care visits at a large urban VA facility and a large integrated private health-care system. The errors occurred from October 2006 through September 2007.

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In 190 cases, 68 unique diagnoses were missed. Most missed diagnoses were conditions commonly seen in primary care, with the most common being pneumonia (6.7%), decompensated congestive heart failure (5.7%), acute renal failure (5.3%) primary cancer (5.3%), and urinary tract infection or pyelonephritis (4.8%). 

Most process breakdowns involved the patient-practitioner clinical encounter (78.9%), such as problems with history-taking (56.3%), examination (47.4%), and/or ordering diagnostic tests for further workup (57.4%). However, some breakdowns were related to referrals (19.5%) patient-related factors (16.3%), follow-up and tracking of diagnostic information (14.7%), and performance and interpretation of diagnostic tests (13.7%). At least two of these processes were involved in 43.7% of cases.


  1. Singh H. JAMA Intern Med. 2013; doi:10.1001/2013.jamainternmed.61.