Article Text

Download PDFPDF
Diagnostic errors in the intensive care unit: a systematic review of autopsy studies
  1. Bradford Winters1,
  2. Jason Custer2,
  3. Samuel M Galvagno Jr1,
  4. Elizabeth Colantuoni3,
  5. Shruti G Kapoor1,
  6. HeeWon Lee4,
  7. Victoria Goode5,
  8. Karen Robinson6,
  9. Atul Nakhasi3,
  10. Peter Pronovost1,
  11. David Newman-Toker7
  1. 1Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, UK
  2. 2Department of Pediatrics, Division of Pediatric Intensive Care, University of Maryland, Baltimore, Maryland, UK
  3. 3Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, UK
  4. 4Johns Hopkins University School of Medicine, Baltimore, Maryland, UK
  5. 5Welch Medical Library, Johns Hopkins University School of Medicine, Baltimore, Maryland, UK
  6. 6Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, UK
  7. 7Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, UK
  1. Correspondence to Dr Bradford Winters, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Baltimore, MD 21287, UK; bwinters{at}


Context Misdiagnoses may be an underappreciated cause of preventable morbidity and mortality in the intensive care unit (ICU). Their prevalence, nature, and impact remain largely unknown.

Objectives To determine whether potentially fatal ICU misdiagnoses would be more common than in the general inpatient population (∼5%), and would involve more infections or vascular events.

Data sources Systematic review of studies identified by electronic (MEDLINE, etc.) and manual searches (references in eligible articles) without language restriction (1966 through 2011).

Study selection and data abstraction Observational studies examining autopsy-confirmed diagnostic errors in the adult ICU were included. Studies analysing misdiagnosis of one specific disease were excluded. Study results (autopsy rate, misdiagnosis prevalence, Goldman error class, diseases misdiagnosed) were abstracted and descriptive statistics calculated. We modelled the prevalence of Class I (potentially lethal) misdiagnoses as a non-linear function of the autopsy rate.

Results Of 276 screened abstracts, 31 studies describing 5863 autopsies (median rate 43%) were analysed. The prevalence of misdiagnoses ranged from 5.5%–100% with 28% of autopsies reporting at least one misdiagnosis and 8% identifying a Class I diagnostic error. The projected prevalence of Class I misdiagnoses for a hypothetical autopsy rate of 100% was 6.3% (95% CI 4.0% to 7.5%). Vascular events and infections were the leading lethal misdiagnoses (41% each). The most common individual Class I misdiagnoses were PE, MI, pneumonia, and aspergillosis.

Conclusions Our data suggest that as many as 40 500 adult patients in an ICU in USA may die with an ICU misdiagnoses annually. Despite this, diagnostic errors receive relatively little attention and research funding. Future studies should seek to prospectively measure the prevalence and impact of diagnostic errors and potential strategies to reduce them.

  • Critical care
  • decision analysis
  • decision making
  • decision support
  • clinical
  • healthcare quality improvement
  • diagnostic errors
  • human factors
  • medical education
  • adverse events
  • epidemiology and detection
  • anaesthesia
  • evidence-based medicine

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


  • Funding SMG was supported by an NIH training grant awarded to the Johns Hopkins University School of Medicine; DN-T was supported in part by a grant from the Agency for Healthcare Research and Quality (HS017755-01).

  • Competing interests BWinters reports fees for expert testimony at several defense and plaintiff law firms and speaking honoraria from 3M corporation and various health systems to speak on patient safety and Rapid Response Systems. PP reports receiving grant or contract support from the Agency for Healthcare Research and Quality, the National Institutes of Health, the Robert Wood Johnson Foundation and The Commonwealth Fund for research related to measuring and improving patient safety; honoraria from various hospitals and healthcare systems and the Leigh Bureau to speak on quality and safety; consultancy with the Association for Professionals in Infection Control and Epidemiology, Inc.; and book royalties for authoring “Safe Patients, Smart Hospitals: How One Doctor's Checklist Can Help Us Change Health Care from the Inside Out.” The following authors report no conflicts of interest: JC, EC, SGK, HWL, VG, KR, AN; SMG and DN-T have no further conflicts beyond what is reported under funding.

  • Provenance and peer review Not commissioned; externally peer reviewed.