Table 1

Cognitive factors related to missed and delayed diagnosis (N=251 responses from 198 respondents)

Examples*N (%)
Cognitive contributory factor
 Knowledge base inadequate or defectiveInsufficient knowledge of relevant condition50 (19.9)
 Faulty detection or perceptionSymptom, sign or finding should be noticeable, but clinician misses it32 (12.7)
 Failure to order or follow-up on appropriate testClinician does not use an appropriate test to confirm a diagnosis or does not take appropriate next step after test24 (9.6)
 Overestimating or underestimating usefulness or salience of a findingClinician is aware of symptom but either focuses too closely on it to the exclusion of others or fails to appreciate its relevance23 (9.2)
 Failure to act soonerDelay in appropriate data-analysis activity17 (6.8)
 Misidentification of a symptom or signOne symptom is mistaken for another17 (6.8)
 Ineffective, incomplete, or faulty history and physical examinationFailure to collect appropriate information from the initial interview and examination16 (6.4)
 Premature closureFailure to consider other possibilities once an initial diagnosis has been reached13 (5.2)
 Distraction by other goals or issuesOther aspects of patient treatment are allowed to obscure diagnostic process for current condition10 (4.0)
 Failure to consultAppropriate expert is not contacted10 (4.0)
System factors (N=201)
Related to diagnostic tests35 (17%)
  Wait time for ordered testProcedures not available in a timely manner19
  Wait time for resultsDelay in receiving test results14
Related to follow-up and tracking issues39 (19%)
  Physician not alerted to abnormal resultsRadiologist did not call about abnormal x-ray, unreported abnormal lab result, buried in chart7 (3.5)
  Physician did not follow-up or delayed follow-up with patient about resultsPhysician believed abnormal result notification was computerised, Physician did not follow-up on negative mammogram with patient and missed patient's continued symptoms7 (3.5)
  Physician missed test resultsPhysician missed results due to information overload (excessive emails), did not see the results in a timely manner, physician was out on disability leave7 (3.5)
Related to referral issues62 (30.9)
  Wait time issuesLong wait for procedures and consultations40 (19.9)
  Communication and/or coordination issues between PCP and specialistLack of communication between specialist and PCP to complete work up11 (5.5)
  Lack of appropriate action on requested consultationThe referral was sent, but the specialty department did not schedule patient11 (5.5)
General system issues65 (32%)
  Workload issuesLack of time with patient, lack of time review documentation at visit, high number of patients, too few PCPs, nursing staff turnover, resource issues, reverse incentives for specialty code in HMO31 (15.4)
  Coordination issuesMultiple providers10 (5.0)
  Chart availability issuesDocumentation not available at the time of the visit or the information is incorrect8 (4.0)
  • * Adapted from Graber et al,16 Archives of Internal Medicine 2005.

  • Percentages do not add to 100% because we report only the 10 most common cognitive and non-cognitive factors.

  • HMO, health maintenance organisation; PCP, primary care physician.