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Diagnostic error among vulnerable populations presenting to the emergency department with cardiovascular and cerebrovascular or neurological symptoms: a systematic review
  1. Svetlana Herasevich1,
  2. Jalal Soleimani1,
  3. Chanyan Huang2,
  4. Yuliya Pinevich1,
  5. Yue Dong1,
  6. Brian W Pickering1,
  7. Mohammad H Murad3,
  8. Amelia K Barwise4,5
  1. 1 Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
  2. 2 Department of Anaesthesiology, Sun Yat-sen University First Affiliated Hospital, Guangzhou, Guangdong, China
  3. 3 Center for Science of Healthcare Delivery, Division of Preventive Medicine, Mayo Clinic, Rochester, Minnesota, USA
  4. 4 Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA
  5. 5 Bioethics Research Program, Mayo Clinic, Rochester, MN, USA
  1. Correspondence to Dr Svetlana Herasevich, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Rochester, Rochester, MN 55905, USA; Herasevich.Svetlana{at}


Background Diagnostic error (DE) is a common problem in clinical practice, particularly in the emergency department (ED) setting. Among ED patients presenting with cardiovascular or cerebrovascular/neurological symptoms, a delay in diagnosis or failure to hospitalise may be most impactful in terms of adverse outcomes. Minorities and other vulnerable populations may be at higher risk of DE. We aimed to systematically review studies reporting the frequency and causes of DE in under-resourced patients presenting to the ED with cardiovascular or cerebrovascular/neurological symptoms.

Methods We searched EBM Reviews, Embase, Medline, Scopus and Web of Science from 2000 through 14 August 2022. Data were abstracted by two independent reviewers using a standardised form. The risk of bias (ROB) was assessed using the Newcastle-Ottawa Scale, and the certainty of evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation approach.

Results Of the 7342 studies screened, we included 20 studies evaluating 7436,737 patients. Most studies were conducted in the USA, and one study was multicountry. 11 studies evaluated DE in patients with cerebrovascular/neurological symptoms, 8 studies with cardiovascular symptoms and 1 study examined both types of symptoms. 13 studies investigated missed diagnoses and 7 studies explored delayed diagnoses. There was significant clinical and methodological variability, including heterogeneity of DE definitions and predictor variable definitions as well as methods of DE assessment, study design and reporting.

Among the studies evaluating cardiovascular symptoms, black race was significantly associated with higher odds of DE in 4/6 studies evaluating missed acute myocardial infarction (AMI)/acute coronary syndrome (ACS) diagnosis compared with white race (OR from 1.18 (1.12–1.24) to 4.5 (1.8–11.8)). The association between other analysed factors (ethnicity, insurance and limited English proficiency) and DE in this domain varied from study to study and was inconclusive.

Among the studies evaluating DE in patients with cerebrovascular/neurological symptoms, no consistent association was found indicating higher or lower odds of DE. Although some studies showed significant differences, these were not consistently in the same direction.

The overall ROB was low for most included studies; however, the certainty of evidence was very low, mostly due to serious inconsistency in definitions and measurement approaches across studies.

Conclusions This systematic review demonstrated consistent increased odds of missed AMI/ACS diagnosis among black patients presenting to the ED compared with white patients in most studies. No consistent associations between demographic groups and DE related to cerebrovascular/neurological diagnoses were identified. More standardised approaches to study design, measurement of DE and outcomes assessment are needed to understand this problem among vulnerable populations.

Trial registration number The study protocol was registered in the International Prospective Register of Systematic Reviews PROSPERO 2020 CRD42020178885 and is available from:

  • Diagnostic errors
  • Patient safety
  • Emergency department

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

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Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

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  • Contributors SH, AKB and MHM contributed to the design of the study. SH, JS, CH, JP, YD and AKB screened articles for inclusion and abstracted data from included studies. SH, AKB, BWP and MHM contributed to analysis, and interpretation of the data. SH and AKB drafted the manuscript. All authors (SH, JS, CH, JP, YD, MHM, BWP and AKB) critically revised the article for important intellectual content and approved the final version of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

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

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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