A recent analysis of several dozen closed ED malpractice claims revealed failed opportunities to avert diagnostic errors and bad outcomes.1

“We wanted to obtain deeper insights from claims data to identify opportunities for improvement in the ED and then translate these opportunities into action,” says Hardeep Singh, MD, MPH, study co-author. “We used a multidisciplinary and collaborative lens, [and] a well-established diagnostic safety framework, to analyze ED cases with an aim of reducing risk.”

This approach made it possible to gain deeper aggregate insights than studying individual cases in silos. “Findings can then be useful to informing ED clinical practice,” Singh adds.

Emergency physicians (EPs), risk managers, and patient safety professionals analyzed 62 claims that closed between 2008 and 2015 at a large malpractice insurer. The following are some of the final diagnoses in the cases in which errors were made:

  • Epiglottis. Radiology did not communicate to ED providers a significantly abnormal neck X-ray finding. Additionally, a CT scan of the neck was canceled because the patient was unable to lie flat;
  • Aortic dissection. Staff incorrectly interpreted a widened mediastinum on chest X-ray as “technique-related.” Another factor was that the patient’s pain improved with hydromorphone. This resulted in the ED provider canceling a CT scan;
  • Testicular torsion. Several young males who complained of abdominal discomfort did not undergo genital exams. These patients were discharged with an incorrect diagnosis of gastroenteritis;
  • Cauda equina syndrome. An MRI was ordered immediately after the EP evaluated the patient, but there was a seven-hour delay;
  • Respiratory arrest. A premature diagnosis of anxiety led to poor outcomes in two patients who complained of shortness of breath and/or chest pain.

Other key findings:

  • There were consultation process issues in 14 cases;
  • Diagnostic tests were a problem in 40% of cases. Of the 25 diagnostic testing errors identified, 14 involved a treating provider misinterpreting clinical data. In six of those 25 cases, irregular findings were not communicated or were delayed;
  • Breakdowns in the patient-provider encounter occurred in two-thirds of cases, most of which involved history-taking or test-ordering. “This is important in the ED context, where both cognitive and systems issues affect diagnosis,” Singh notes.

High-risk Presentations

Abdominal pain, trauma, and neurological conditions were the top clinical presentations involving diagnostic error. “Abdominal pain presentations are of particular risk of missed diagnosis,” Singh emphasizes.

Testicular torsion and bowel perforation were the most frequently missed diagnoses concerning abdominal pain complaints. Two patients with testicular torsion presented with vomiting and left or right lower quadrant pain — but not testicular pain.

“Testicular torsion appears to be a very important missed condition where patients are often younger and may not present with typical testicular pain,” Singh says. It is important for EPs to perform testicular exams in cases of abdominal pain presentation in males, the researchers recommended.

Of the 46 cases that were discharged home initially, 34 returned to the ED later. Almost half of these return patients reported abdominal symptoms at some point prior to seeking care on the first ED visit.

This study’s findings mirror a 2016 analysis of 100 high-risk abdominal patients in the ED. The authors of that analysis found diagnostic errors occurred in 35 of those cases.2 There were breakdowns in the patient-provider encounters in more than two-thirds of this group. History-taking, ordering additional tests, and/or follow-up/tracking diagnostic information were common breakdowns.

The most frequently missed diagnoses were gallbladder pathology (10 cases) and urinary infections (five cases). “All ED personnel should consider these findings as signals for additional improvement,” Singh offers.

QI Activities

“It’s essential to focus on improving systems and processes in the ED with systematic safety data collection that leads to quality improvement activities in areas identified as high risk,” Singh says.

The authors of another 2016 study analyzed the use of a voluntary incident reporting system implemented at two large EDs.3 Of the 509 incidents reported by EPs, 209 were related to diagnosis. The authors identified 214 diagnostic errors.

Voluntary reporting allows reviewers to focus “on the appropriate things, rather than what was most evident,” says Nnaemeka Okafor, MD, MS, the study’s lead author. Since reviewers have more context, they are less likely to simply blame an individual EP for a mistake. For instance, it might be that at the time of the error, a surge of critically ill patients presented. Previously, the ED used a typical peer review process.

“If an error occurred, we’d try to figure out what the causes were. But it didn’t go into granular detail,” Okafor explains. Waiting for the typical “triggers” of peer review, such as return ED visits, took too long and usually involved only egregious errors. In the analysis, only 16% of the reported events resulted in significant harm.

“A good number of the errors that were reported were minor and would have otherwise been swept under the rug or hardly noticed,” Okafor reports.

The voluntary reporting system allows the ED to closely track errors that result in no harm. “Even though they are minor, the next time they come around, it could be a major adverse event that happens,” Okafor says.

A core group of physicians led the voluntary reporting effort. Both new residents and existing faculty were wary of reporting mistakes, whether their own or a colleague’s. “That took some time to overcome,” Okafor notes. The physicians continually reiterated that there would be no negative repercussions from reporting mistakes. They emphasized that the goal was to learn from errors to avoid repeating them. The voluntary error reports shed light on appropriate topics for didactic lectures.

“There were some mistakes that we saw repeated over and over again,” Okafor says. “We knew what behaviors we needed to focus on changing.”

By creating a separate incident reporting system for the ED, reviewers better understand the environmental factors that may have contributed to errors. They are less likely to focus solely on cognitive factors. This makes ED providers more comfortable with the process. “You are getting reviewed by your peers,” Okafor explains.

Asking EPs to review every ED case is difficult at the system level. “We found it was more useful to have the folks who work in the ED review all the ED cases and then feed that into the hospital’s incident reporting system,” Okafor says.

Voluntary reporting in the ED requires buy-in from hospital leaders, the ED medical director, and a core group of physicians.

“Without that, it’s a non-starter,” Okafor advises.

Chandresh Shelat, MD, associate director of the department of emergency medicine at Sinai Hospital in Baltimore, notes that abdominal pain is one of the most common complaints seen in the ED. When abdominal pain is misdiagnosed, in his experience, it is usually because EPs relied too much on a particular test result.

“In the litigation I’ve seen, clinicians tend to rely on just lab values and not the whole clinical picture,” Shelat says. A patient presenting with right lower quadrant pain and a normal white blood cell count is one example. Shelat notes some EPs believe a normal white blood cell count excludes appendicitis, “which is absolutely untrue, but is still common practice.”

Rather than leaning too heavily on any one finding, Shelat says it is important for EPs to ask themselves if everything makes sense. “Even if you don’t come up with a diagnosis, have you at least ruled out serious pathology?”

The authors of the 2018 study are taking these three actions based on their findings:

  • An ED diagnosis collaborative effort is implementing chief complaint-driven interventions at five academic medical centers. For instance, the group will develop a clinical guideline for abdominal pain. Then, researchers will review medical records of certain ED patients to determine the quality of the documentation, history, testing, physical exam, and diagnostic imaging;
  • The group is targeting several system failures with standardized transition-of-care processes. ED providers will be made aware of the process breakdowns inherent at each phase of patient care;
  • Researchers are developing institution-specific simulation programs to address the cognitive, system, and process issues that were identified. One ED designed a program to improve abdominal pain assessment starting at triage.

“All EDs should build dedicated infrastructures and teams to gather, analyze, learn from, and act upon error-related data,” Singh advises.


  1. Lemoine N, Dajer A, Konwinski J, et al. Understanding diagnostic safety in emergency medicine: A case-by-case review of closed ED malpractice claims. J Healthc Risk Manag 2018;38:48-53.
  2. Medford-Davis L, Park E, Shlamovitz G, et al. Diagnostic errors related to acute abdominal pain in the emergency department. Emerg Med J 2016;33:253-259.
  3. Okafor N, Payne VL, Chathampally Y, et al. Using voluntary reports from physicians to learn from diagnostic errors in emergency medicine. Emerg Med J 2016;33:245-252.


  • Nnaemeka Okafor, MD, MS, Assistant Professor, Department of Emergency Medicine, McGovern Medical School, UTHealth; Medical Director, Medical Informatics, Acute Care Services, Memorial Hermann-Texas Medical Center, Houston. Email: nnaemeka.g.okafor@uth.tmc.edu.
  • Hardeep Singh, MD, MPH, Chief, Health Policy, Quality & Informatics Program, Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center/Baylor College of Medicine, Houston. Phone: (713) 794-8515. Email: hardeeps@bcm.edu.