Table 1.
The details of 16 diagnostic error cases.
| Case No.a | Age (y) | Sexb | Physician of first contact |
Chief complaint | Initial diagnosis |
Final diagnosis |
Index visit to final diagnosis (days), n |
Outcome categoryc | Initial diagnosis was on listd | Final diagnosis was on listd |
| 1 | 95 | F | Resident | Fever | URIe | Cholangitis | 4 | F | No | No |
| 2 | 76 | M | Resident | Abdominal pain | GERDf | Cholecystitis | 2 | F | Yes; rank 4 |
No |
| 3 | 83 | M | Resident | Abdominal pain | Costochondritis | Pneumonia | 3 | F | No | No |
| 4 | 55 | M | Resident | Hematochezia | Infectious enteritis | Diverticular bleeding | 2 | F | Yes; rank 3 |
Yes; rank 1 |
| 5 | 89 | F | Staff | Nausea | Unknown | Acute pyelonephritis | 3 | F | No | No |
| 6 | 75 | M | Staff | Cough | URI | Interstitial pneumonia | 3 | F | No | Yes; rank 10 |
| 7 | 66 | M | Resident | Abdominal pain | Constipation | Intestinal obstruction | 6 | F | Yes; rank 4 |
No |
| 8 | 70 | F | Staff | Cough | Unknown | Heart failure | 3 | F | No | Yes; rank 8 |
| 9 | 77 | F | Resident | Palpitation | Heart failure | Pulmonary embolism | 2 | E | Yes; rank 10 |
No |
| 10 | 82 | M | Staff | Fever | URI | Cholecystitis | 3 | F | No | No |
| 11 | 81 | F | Resident | Anorexia | Choledocholithiasis | Acute pyelonephritis | 2 | C | No | No |
| 12 | 72 | M | Staff | Headache, lightheadedness | Fatigue | Vestibular neuritis | 8 | E | No | No |
| 13 | 86 | M | Resident | Abdominal pain | Enteritis | Intestinal obstruction | 0g | F | No | Yes; rank 9 |
| 14 | 78 | M | Staff | Abdominal pain | Hemorrhoid | Infectious enteritis | 9 | C | No | No |
| 15 | 91 | M | Staff | Fever, cough, back pain | URI | Acute pyelonephritis | 7 | F | No | Yes; rank 3 |
| 16 | 72 | M | Resident | Dyspnea, cough, malaise | URI | Interstitial pneumonia | 11 | F | No | No |
aAll diagnoses were common. All cases had typical presentations except for case 2.
bFemale (F) or male (M).
cOutcome was classified, along with the Safer Dx Process Breakdown Supplement, as follows: Category C, “An error occurred that reached the patient but did not cause the patient harm”; Category E, “An error occurred that may have contributed to or resulted in temporary harm to the patient and required intervention”; Category F, “An error occurred that may have contributed to or resulted in temporary harm to the patient and required initial or prolonged hospitalization” [29].
dAI Monshin’s differential list; where a diagnosis was on the list, its rank on the list is indicated.
eURI: upper respiratory infection.
fGERD: gastroesophageal reflux disease.
gThe final diagnosis was made at the second visit, which was on the same day as the index visit.