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Cognitive Errors and Logistical Breakdowns Contributing to Missed and Delayed Diagnoses of Breast and Colorectal Cancers: A Process Analysis of Closed Malpractice Claims

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Abstract

PURPOSE

To erform a process analysis of missed and delayed diagnoses of breast and colorectal cancers to identify: (1) the cognitive and logistical factors that lead to these diagnostic errors, and (2) prevention strategies.

METHODS

Using 56 cases (43 breast, 13 colon) of missed and delayed diagnosis, we performed structured analyses to identify specific points in the diagnostic process in which errors occurred. Each error was classified as either a cognitive error or logistical breakdown. Finally, two physician-investigators identified strategies to prevent the errors in each case.

RESULTS

Virtually all cases involved one or more cognitive errors (53/56, 95 %) and approximately half (31/56, 55 %) involved logistical breakdowns. The clinical activity most prone to cognitive error was the selection of the diagnostic strategy, both during the office visit (25/56, 45 %) and during interpretation of test results (22/50, 44 %). Arrangement of follow-up visits with a primary care physician (8/29, 28 %) or specialist physician (7/29, 26 %) were especially prone to logistical breakdowns. Adherence to current clinical guidelines could have prevented at least one error in 66 % of cases and assistance from a patient advocate could have prevented at least one error in 48 % of cases.

CONCLUSIONS

Cognitive errors and logistical breakdowns are common among missed and delayed diagnoses of breast and colorectal cancers. Prevention strategies should focus on ensuring improving the effectiveness and use of clinical guidelines in the selection of diagnostic strategy, both during office visits and when interpreting test results. Tools to facilitate communication and to ensure that follow-up visits occur should also be considered.

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Acknowledgements

Contributors

No relevant contributors beyond the list of study co-authors.

Funders

This study was supported by grants from the Agency for Healthcare Research and Quality (HS011886-03) and the Harvard Risk Management Foundation.

Prior Presentations

Material presented in this manuscript constitutes an original secondary analysis of a case series previously published in the Annals of Internal Medicine.4 An early version of the abstract was presented orally at the Society of General Internal Medicine Annual Conference.

Conflict of Interest

The authors declare that they do not have a conflict of interest.

Author information

Authors and Affiliations

  1. Division of General Medicine and Primary Care, Department of Medicine, Brigham & Women’s Hospital, 3/F 1620 Tremont Street, Boston, MA, 02120, USA

    Eric G. Poon MD, MPH, Allen Kachalia MD, JD & Tejal K. Gandhi MD, MPH

  2. The Harvard Risk Management Foundation, Cambridge, MA, USA

    Ann Louise Puopolo BSN, RN

  3. Harvard School of Public Health, Boston, MA, USA

    David M. Studdert LLB, ScD

  4. Harvard Medical School, Boston, MA, USA

    Eric G. Poon MD, MPH, Allen Kachalia MD, JD & Tejal K. Gandhi MD, MPH

  5. Melbourne School of Population Health, University of Melbourne, Parkville, Australia

    David M. Studdert LLB, ScD

Authors
  1. Eric G. Poon MD, MPH
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  2. Allen Kachalia MD, JD
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  3. Ann Louise Puopolo BSN, RN
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  4. Tejal K. Gandhi MD, MPH
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  5. David M. Studdert LLB, ScD
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Corresponding author

Correspondence to Eric G. Poon MD, MPH.

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Poon, E.G., Kachalia, A., Puopolo, A.L. et al. Cognitive Errors and Logistical Breakdowns Contributing to Missed and Delayed Diagnoses of Breast and Colorectal Cancers: A Process Analysis of Closed Malpractice Claims. J GEN INTERN MED 27, 1416–1423 (2012). https://doi.org/10.1007/s11606-012-2107-4

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  • DOI: https://doi.org/10.1007/s11606-012-2107-4

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