Hidden In Plain Sight: Exposing the Drivers of Diagnostic Error

This white paper is the second in a three-part series that explores diagnostic error in three different care settings: emergency department, office-based practices, and inpatient care. It is based on an analysis of five years of closed medical malpractice events (2020-2024).

Included in the report is a self-assessment tool to identify crucial best practices that address contributing factors identified in our data and five key steps to mitigate risk in office practices.

Five Key Takeaways:

1. 27% of all malpractice events closed during the five-year period studied involved diagnostic error (this includes all locations, not just the three addressed in this series).
2. Diagnostic error occurs most frequently in office-based settings accounting for 34% of diagnosis-related events.
3. 45% of office-based events alleged a missed cancer diagnosis. The most common missed cancers were prostate, lung, breast, and colorectal.
4. One-third of office-based diagnostic error events resulted in a patient death, and 22% resulted in a patient suffering a high severity injury. Together, these tragic events accounted for 72% of the indemnity paid.
5. Understanding and addressing the key vulnerabilities and most frequently missed diagnoses identified in this report can significantly reduce diagnostic error in the office setting.