In December 2022, Newman-Toker et al., published a systematic review on emergency department (ED) diagnostic errors with funding from the Agency for Healthcare Research and Quality (AHRQ). CNN highlighted its findings: 7.4 million annual U.S. ED misdiagnoses, 2.6 million harms from preventable errors, and >100,000 permanent, high severity disabilities, and more than 250,000 deaths. According to the study, nearly 6% of ED visits are misdiagnosed.

In unison, the emergency medicine community recoiled.

Proposing that emergency medicine errors are a leading cause of death, behind heart disease, cancer, and COVID-19, but ahead of all accidents and strokes defies belief. Diving into the methods, it’s clear why. The data supporting these extrapolations are, in a manner of speaking, anemic. Emergency medicine societies, led by American College of Emergency Physicians (ACEP), called them “misleading, incomplete, and erroneous”. ACEP insisted CNN change their article to reflect these objections.

I have something to admit. I was involved. I was a technical expert and peer reviewer. I gave feedback when the authors created search strategies in 2020 via a one-hour Zoom. In 2021, I gave written feedback on a draft. My name is listed prominently on Page 6, which caused me to get doxxed on EMDocs. When the report dropped, people reached out.

A few examples:

“I saw the CNN news story. Did you agree with this?”

“Your name was on the AHRQ report. What was your role?”; and

“What the actual eff?”

My purpose in writing this article is two-fold. First, to briefly defend the technical experts and reviewers. More importantly, how this unfolded is a tragically, missed opportunity to have a discussion about errors. Useful takeaways exist within the dense 744-page tome if you can ignore its erroneous extrapolations and read beyond the abstract.

Regarding my involvement, I was critical of the report’s definition of medical errors. In reference to its national estimates, I wrote it had, “…a fatal flaw and should be removed….Headline grabbing, yes, but this is at best gravely misleading”. The authors disagreed with my review. Other reviewers made similar comments. The reviewers didn’t write it. Having reviewed it doesn’t mean that I, or other reviewers, approve.

I won’t recount our criticisms here, but many were similar ACEP’s.  Suffice it to say, medical error research is complicated. Causes for some diagnostic errors are clear. Yet for many, there is no gold standard of diagnostic truth or smoking gun. It’s sometimes impossible to reliability assign root causes for diagnostic errors even with full vetting. Therefore, my view is that combining studies across different populations from different EDs in different countries at different times that define errors in different ways is not meaningful. However, I found some of more qualitative themes useful. Below I describe my four takeaways.

1. Know the Malpractice Hotspots

Certain conditions cause more malpractice claims. Yet malpractice allegations are not perfect proxies for diagnostic error rates. Malpractice cases involve an alleged standard of care breach, a large potential payout, and a poor outcome. Nevertheless, malpractice hotspots are good to know (Table 1). Malpractice allegations, even if dismissed, have negative psychological impacts on physicians and take years to resolve. Malpractice hotspots are a good starting point for developing clinical protocols. Protocols can often vaccinate against litigation and improve safety. Say you discharge a HEART score of 3 after appropriate testing. You document that the risk for short-term cardiac events is low (~1%). When lawyers review your “missed” acute myocardial infarction, it’s clear standard of care was followed and the case is often avoided.

2. Beware of Atypical Presentations

Atypical (i.e. non-classic) presentations of serious conditions surround malpractice hotspots (Table 2). No emergency physician misses obvious strokes (e.g. slurred speech / arm weakness). But it’s easier to miss when the only symptom is vertigo. When evaluating vertigo, a useful bedside test called the Head Impulse-Nystagmus-Test of Skew (HINTS) exam can help differentiate central versus peripheral symptoms. Additionally, emergency physicians should have a low threshold to thoroughly work-up and consult a specialist for new objective, neurologic findings. A painful abdomen is another area where serious conditions can hide, particularly in older adults. Abdominal CT findings have consistently surprised me more than any other ED test. My rule of thumb: if in any doubt, CT (or ultrasound if a child); if the patient is old, don’t think. CT everyone with new abdominal pain.

3. Root Causes of Errors are most often “Thinking” Problems

ED diagnosis is a complex cognitive process, drawing incomplete information from history, prior data from disparate sources, a physical exam, and interpreting diagnostic tests. It is quite miraculously reliable, particularly with expectations of treating more than two patients per hour and increasing emergency department crowding and boarding. Because thinking problems dominate as root causes of malpractice cases (Table 3), standardizing your approach can improve safety. This involves creating protocols for high-risk complaints for malpractice hotspots, particularly where symptoms can be atypical. For example, lower back pain almost always non-serious but a small minority have cord compression. Hardwiring a red flag assessment and a complete lumbar plexus exam into every back pain evaluation may help reduce misdiagnosis.

4. SPADE is a good way to track errors

The Symptom-disease Pair Analysis of Diagnostic Error (SPADE) methodology can track ED misdiagnosis of stroke, myocardial infarction, aortic dissection, spinal cord compression, and others. When a trigger condition is diagnosed, a look back can assess for related prior visits. For example, when stroke is diagnosed, recent visits with dizziness, vertigo, or nausea/vomiting should prompt a chart review. SPADE measures could also be developed to assess ED-level quality.

In closing, there are real concerns with parts of the report. But I sincerely hope it’s not outright dismissed, especially given all the energy invested in producing it. Nevertheless, it will undoubtedly be a main course at ED residency journal clubs for years to come. A final bit of advice in this regard. You can’t do justice to the entire report in a single journal club, or even read it in one sitting. Don’t try. Break it into pieces for reading and discussions. Set a goal to understand a few key questions, rather than superficially scanning the whole report.

Table 1: The 15 top emergency medicine malpractice hotspots (in rank order)

1. Stroke
2. Acute myocardial infarction
3. Aortic aneurysm/dissection
4. Spinal cord compression/injury
5. Venous thromboembolism
6. Meningitis/encephalitis
7. Sepsis
8. Lung cancer
9. Traumatic Brain Injury / traumatic intracranial hemorrhage
10. Arterial thromboembolism
11. Spinal/intracranial abscess
12. Cardiac arrhythmia
13. Pneumonia
14. Gastrointestinal perforation/rupture
15. Intestinal obstruction

Adapted from: Newman-Toker et al. Diagnostic Errors in the Emergency Department: A Systematic Review. 2022. Data were drawn from a large database of emergency medicine malpractice claims. The list is in the order of the most common conditions causing serious misdiagnosis-related harms.

Table 2: Common serious ED conditions that present with atypical symptoms

Adapted from: Newman-Toker et al. Diagnostic Errors in the Emergency Department: A Systematic Review. 2022. Data on these conditions were drawn from several studies in the systematic review. 

Table 3: The 10 most common “root causes” identified in ED malpractice litigation (in rank order)

1. Thinking problems (i.e. clinical judgment)
2. Issues with communication
3. Issues related to documentation
4. Issues related to lack of insurance
5. Clinical environment
6. Behavior-related
7. Administrative issues
8. Supervision issues
9. Technical skill
10. Electronic health records

Adapted from: Newman-Toker et al. Diagnostic Errors in the Emergency Department: A Systematic Review. 2022. Data were drawn from a large database of emergency medicine malpractice claims.

Jesse M. Pines, MD, MBA, MSCE is the National Director of Clinical Innovation at US Acute Care Solutions. and a Professor of Emergency Medicine at Drexel University.