TABLE 2.
Physician-Related Pitfalls in the Diagnostic Processa,b in 163 Medico-Legal Cases Involving Physicians; Canadian Medical Protective Association Cases Closed 2011–2020
| Phase of Diagnostic Process | n (%) | Example From Cases |
|---|---|---|
| Access and presentation | 0 (0) | None |
| History | 31 (19.0) | Failing to question patients in detail about risk factors for infection |
| Not reviewing a medical chart that included abnormal findings by a previous physician | ||
| Physical examination | 66 (40.5) | Not listening to the patient’s chest at any repeat visit for the same health issue |
| Conducting a suboptimal (superficial) examination on a deteriorating patient with concerning vital signs | ||
| Testing | 80 (49.1) | Not conducting a full septic work-up when indicated for a patient under 12 mo old |
| Misinterpreting a postoperative CT image showing the source of infection | ||
| Delaying to follow-up on a positive blood culture after discharging a patient from the emergency department | ||
| Assessment | 123 (75.5) | Wrongly attributing signs or symptoms in adult patients to illicit drugs or prescription medications |
| Not recognizing the signs and symptoms of septic shock thereby delaying treatment | ||
| Failing to consider an alternative diagnosis when the treatment response was not sustained or a patient was deteriorating | ||
| Referral or consultation | 48 (29.4) | Delaying or not requesting a second opinion when the diagnosis was unclear |
| Delaying transfer of a patient with significant signs and symptoms to a tertiary hospital | ||
| Follow-up | 7 (4.3) | Performing no further investigations after the clinical encounter to confirm or rule out a diagnosis |
a
Each pitfall represents documented peer expert criticisms of a physician’s care in the medico-legal record. A single case may have had multiple pitfalls.
b
Using the Diagnosis Error Evaluation and Research taxonomy (23) defined in Appendix 6 (http://links.lww.com/CCX/B128).