LinkedIn Facebook Twitter Email

Managing diagnostic errors in primary, ambulatory, and emergency care

Sandra Chellew, MBA, RN, CPHRM, CPHQ
Managing diagnostic errors in primary, ambulatory, and emergency care

Diagnostic errors are among the most significant patient safety problems in American healthcare, resulting in death or disability nearly twice as often as other types of clinical mistakes. The vast majority of these errors — which can take the form of missed, incorrect, or delayed diagnoses — occur in outpatient settings, where more than 12 million adults are misdiagnosed each year.1

We researched three common outpatient care settings to identify their most common causes for diagnostic errors. The solutions below can help healthcare risk managers anticipate and mitigate these errors.

Top diagnostic errors in primary care

The top issues in the primary care setting are mostly related to systems and patients.

Top issues

  • Poor communication between primary and secondary care providers
  • Lack of access to medical care and/or social support mechanisms
  • Multiple symptoms and/or underlying conditions, including psychiatric disorders
  • Patient’s limited general education and/or understanding of health matters
  • Deficiencies in continuity of care and follow-up
  • Provider workload and time constraints


  • Communicate with patients regarding abnormal test results and plan of care.
  • Improve communication between caregivers during patient handoffs.
  • Keep open channels, such as hotlines, for reaching specialists quickly.
  • Maintain referral guidelines and protocols for significant conditions.
  • Participate in continuing education courses focused on often-overlooked conditions.
  • Examine delayed diagnoses to assess causes and prevention.

Top diagnostic errors in ambulatory care

For patients receiving ambulatory care, causes of incorrect or delayed diagnoses can be related to the provider or the patient.

Top issues

  • Judgment failure by the care provider
  • Memory failure or lack of vigilance
  • Heavy workload
  • Unclear lines of responsibility
  • Inadequate supervision
  • Poor documentation
  • Failure to order appropriate diagnostic tests
  • Insufficient clinical knowledge
  • Complex patient history
  • Incomplete patient history or inadequate physical exam
  • Inaccurate reading of a diagnostic test
  • Poor communication at patient handoff
  • Failure to initiate a referral
  • Lack of an adequate follow-up plan
  • Patient’s failure to comply with the follow-up plan


  • Computerize systems to reduce reliance on memory.
  • Follow protocols/checklists based on approved diagnostic measures for common conditions.
  • Encourage second opinions in complex cases.
  • Follow a structured communication process for handoffs to other groups of caregivers.
  • Carry out prompt over-reads of film(s) or tests that are outside normal areas of expertise.
  • Improve scheduling to minimize heavy workloads.
  • Detail processes for reviewing test results and communicating with providers and patients.
  • Take steps to ensure patient follow-up and address no-shows.

Top diagnostic errors in emergency departments

The challenges in emergency departments are similar to those in ambulatory care, but are often compounded by the range of disciplines required and the increased volume of patients.

Top issues

  • Mistakes in judgment
  • Inadequate technical knowledge or skill
  • Vigilance or memory issues
  • Heavy workload
  • Inadequate supervision
  • Failure to order appropriate diagnostic tests
  • Incomplete patient history or inadequate physical exam
  • Inaccurate reading of a diagnostic test
  • Lack of consultation
  • Cognitive issues
  • Incomplete handoff
  • Patient-related factors


  • Protocols for diagnoses that have high potential to be overlooked
  • Staffing and scheduling to allow enough time for supervision of trainees
  • Clinical competency of all trainees and providers
  • Handoff procedures involving clinical communications
  • Processes and systems specific to the patient population
  • Patient histories and physical exams
  • Test ordering and evaluation
  • Consultations and referrals
  • Patient education
  • Tracking planned and unplanned returns to the emergency department
    • Evaluation of claims data that may include diagnostic-related issues
    • Reporting of critical test results to identify actual or potential lapses
    • Patient satisfaction surveys
    • Decision support systems

The Swiss cheese effect

One classic way to understand accidents is to imagine a stack of slices of Swiss cheese. Each slice may have holes, but a hole only passes all the way through the stack if it is located in the same place on multiple slices. In much the same way, one error can be caught and corrected, but multiple errors or breakdowns that coincide with each other can lead to serious consequences.

Time and resource constraints often contribute to this Swiss cheese effect, which only reinforces the need for entities to use quality improvement and peer review methodologies to streamline and improve in certain areas.

Efficiency, quality, and safety typically go together to achieve positive patient care outcomes. In meeting those objectives, an organization’s reputation may be protected, and financial losses, including potential increases in professional liability insurance premiums, may be minimized.

Learn more

For more information and a more detailed guide, read our report, “Risk-management implications of a missed, incorrect, or delayed diagnosis,” by Sandra Chellew, MBA, RN, CPHRM, CPHQ.

Liberty Mutual creates protective partnerships with healthcare businesses, providing solutions for complex risks and expertise that delivers. Learn more about how we support the full range of healthcare organizations with their risk management and mitigation.

1. Muhrer, J.C. (2021), Risk of misdiagnosis and delayed diagnosis with COVID-19: A Syndemic Approach, The Nurse Practitioner, 46(2): 44-49.

Scott, Kirstin and Vayo, Tracy, The Top Seven Analytics-Driven Approaches to Reducing Diagnostic Error and Improving Patient Safety, Health Catalyst, October 13, 2016.
Muhrer J. C. (2021). Risk of misdiagnosis and delayed diagnosis with COVID-19: A Syndemic Approach. The Nurse Practitioner, 46(2), 44–49.
Diagnostic Errors More Common, Costly and Harmful Than Treatment Mistakes, COVID-19 Update, Johns Hopkins Medicine, April 23, 2013.
Car, Lorraine Tudor, et al., Clinician-identified problems and solutions for delayed diagnosis in primary care: a PRIORITIZE study, BMC Family Pract. 2016; 17(1):131.
Gandi, Tejal K, MD, MPH, et al., Missed and Delayed Diagnoses in the Ambulatory Care Setting: A Study of Closed Malpractice Claims, Annals of Internal Medicine, American College of Physicians, Volume 145. Number 7, October 2006.
Kachalla, Allen MD, JD, et al., Missed and Delayed Diagnoses in the Emergency Department: A Study of Closed Malpractice Claims From 4 Liability Insurers, Annals of Emergency Medicine, American College of Emergency Physicians, Volume 49, No. 2: February 2007.

This website is general in nature, and is provided as a courtesy to you. Information is accurate to the best of Liberty Mutual’s knowledge, but companies and individuals should not rely on it to prevent and mitigate all risks as an explanation of coverage or benefits under an insurance policy. Consult your professional advisor regarding your particular facts and circumstance. By citing external authorities or linking to other websites, Liberty Mutual is not endorsing them.